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- _ � <br /> _ � <br /> . � . . . <br /> .WOODJBURNING EQUIPMENT . . -- .- <br /> Wood stove with flue � <br /> Wood combination or add-on _ <br /> Factory fueplace with flue � � <br /> - Factory Fireplace (s) Freestanding Masonry � <br /> Wood Stove (s) Franklin, other � <br /> Brand Name Model No. <br /> Mfgr's Min., Clearances, side , rear , mi.n. flue dia. � <br /> Total <br /> yENTILATION <br /> No. Kitchen E.�haust ducted recirculati.ng �� <br /> No. Bath Exhaust (must be ducted outside) �� � <br /> No. Other Fans: Locations �� • <br /> . 'T�t:�? <br /> FU�L STORAGE (MUST BE APPROVED BY FIRE MARSHAL) <br /> Installation Removal � <br /> Fuel oil: gallons underground i.nside outside <br /> LP Gas: gallons ' <br /> Other Gas opening <br /> PERMIT F'EE CALCULATION <br /> 1. 1.25%o of Contract Price* or IViinimum Fee i�35.ti0) �b5- �- <br /> _ !' �--- x .0125 $ <br /> (contract pnce) <br /> 2. State Surchar�e. ** Add the State Buildi.ng Code Division �� ! �� <br /> Surcharge to each permit. �U, `I 60 x .Q005 $ <br /> (contract price) <br /> � or $.50, whichever is greater 1.50 <br /> 3. Posta�e and Handlin� (Only mail-in. applications) $ <br /> 4. TOTAL PERNIIT FEE (Add lines 1-3 above) � ��� � `�� <br /> * CONTRACT PRICE or JOB COST means the actual or estimated dollar amount charged for the permitted <br /> work including materials, labor, profit, and other fixeci cosu. I[ is the ame7unt to be cilargeci to the <br /> � customer for the work done. If any material, equipment, laUor,or installation are furnished by the owner, <br /> � tenant or any other party ihe reasonable market value of such items must be added to the estimated cost <br /> or concract price for permi[ fee purposes. In the event tha[there is a dispate on the amount of the job cost, <br /> the City may request the submission of a signed copy of the actual contiract• <br /> ** The STATE SURCHARGE is .0005 of the contract price under $1,000,000 or $.50 - whichever is <br /> greater. For valuacions over $1,000,000 call the Department of Inspectional Services for the price. <br /> The undersigned hereby applies to the City for issuanc�e of a Mecha.nical Permit+�a Melnnto da <br /> all work in strict accordance with the ordinances oi tne �,ity�� "'� ""lica on are com lete, true <br /> State Buildi.ng Code, and certifies that all statements made o�tb-is app P <br /> and correct --- - - <br /> . � i � _ _ - <br /> C <br /> ._. .. .�. , __- .. , L_ _ _ <br /> _�. �._,._.__ ....�... J / , _ -� <br /> _ � j l� <br /> : � -- Date: � ( f ' <br /> � �,% — <br /> - APPlicant's Signature: ,- �1 ,� i' __ <br /> � <br /> - Date: So� <br /> � ; Agproved By: - -� � <br />