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<br /> , , •y ��/D � �.j/� • j r �I �gP�✓ A
<br /> ✓��� �,..r..r-- -��i..vl...,'r' ,"�'3 .:k�'..� _ ^�:C���T.�� S tev�� /s 4" � /
<br /> . �. ' a'�=?.•�0 .e`.'`` � " • ' � .
<br /> .. �`� ����� �LTRN�NC � �' .� ; . .
<br /> ' . � � � �Vopd stave with flue � .
<br /> � �.Wood combination or add-on . - . . . .
<br /> �� Fa.ciory fueplace with flue � . � M�so�xy -
<br /> . � �- Factory Fireplace (s} �, Preesta.nding „ . ,
<br /> , . . :•�� Wood Stove (s) Frankliu, other
<br /> r---- � Model No.
<br /> Brand I�ame ' mia. flue dia. �
<br /> Ni�gr'8 Min., Clearauces, side�► rear�, Total � .
<br /> �'�T�—�� z�ecitcU.latiz]
<br /> Kitchen �xhaust ducted � —T— ��
<br /> �No, _�, Gfm
<br /> No. ^�, Bath ��aust {�Lst be ductPd outside) .-- _ cfrn ,
<br /> No. ��,. Other Fans: Locations Tota�
<br /> �t1�Y., ST��S� {MUST BE �FPROVED BY F�tE MARSHAIr?
<br /> Lustallation ,� Removal inside ��, outside
<br /> �~ Fuel oil: _„_ gallons undez'grc�und �
<br /> - � .Lp Cra.s: �._ gallons � Gas openi�ng
<br /> �� Ot�lef �r
<br /> P�RMFT FEE A. C'LrL���� ,'35.00
<br /> 1. 1.�5% of �ontract Pric�* ar M�.nimur�n F x .pX25 $ 35.00
<br /> " (codtract price}
<br /> �, State SurclQa. e. ** Add the St��e ���d� e��e Division
<br /> Surcharge to cach permit• �2 �00,0.0 x .4005 $
<br /> . (CotttrdCt pricC�
<br /> or $.50, wkuchevex is greater Ilcations) $ 1.50
<br /> 3, Posta�e, and �Iandtins (��Y �a�"� �Pp $ 37.50
<br /> c�, TOTAL PER�'� FE� tAdd �ines 1-3 abave)
<br /> *
<br /> CONTFtAGT PRICE or JOB COST�eans the 2ctual or esti�ated doUar auiouat�argcd for tbe pern�.irced
<br /> work uicludiag raaterials, labor, pmfit. and ocher fix�d �asts• It is the amount 4a b�b�����er,
<br /> customer for t�e work done. I f an y u�a t e rial, e q'u Pmenc, labor,Or tIIsta118Exo�arC fl�lsh Y
<br /> tenant or any oiher part}' the r�a�°�'ie ��et value of such items iuesst n��a�t of�th e job costt
<br /> or eantzaet price for p�rmit fea purposes. Iu�e event��erattual cantract•
<br /> the Ciry maY request the submissiou of a si�ed c.opY
<br /> The STATE SURCHARGE is .OQOS of ihe Coutract prica under $1.000,060 or $.50 - whichever is
<br /> '`" Qpp r,a1L the Depar�nenc of Inspcctional Services for che price.
<br /> p�atcr. Fot valuatians over S1,Q00,
<br /> Iies to the City for issuan�e a�a M����' pe�t, agrees to da
<br /> 'i"he undersigned hereby apP and the reg���� tif��M�esata
<br /> all work in strict accaXdance fie��s tha�al��ements madle a this applicadon are complete, rrue
<br /> State Buildi.ag Code, and certl
<br /> and cotrect. -.._._�.--
<br /> . . .. ., ., . -a�., 3 3 9 4
<br /> , . .,�.._ �_y.,�.:`: Date:
<br /> - APPlicant'sSi�turc• ' � g
<br /> . .� , ,- Date: 3 �
<br /> � � . Approved By.'"� � �`
<br />
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