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�VOOD BL12:tiZtiG EQLTIPI'1E�1'I' <br /> `Vood stove with flue <br /> �ood combination or add-on <br /> Factory fireplace with flue <br /> Factory Fireplace (s) Freestandin� Niasonry <br /> �Vood Stove (s) Franklin, other <br /> Brand Name Model No. <br /> VSfar's ��tin., Clearances, side , rear , min. flue dia. <br /> VENTILATION <br /> No. � Kitchen Exhaust � ducted recirculating cfm <br /> No. �_ Bath E:chaust (must be ducted outside) �� <br /> No. � O[her Fans: Locations �ru ,r cfm <br /> FLTEL STOR�GE (i�1UST BE APPROVED BY FIRE MARSHAL) <br /> Installation Removal <br /> Fuel oil: �allons underground inside outside <br /> LP Gas: gallons <br /> Other Gas opening <br /> PERMIT FEE CAI..CULATION <br /> 1. 1.2�90 of Contract Price�` or Minimum Fee (�35.00) l QO•� <br /> ��.�Q x .0125 Q <br /> (contract price) <br /> 2. State Surcharae. ** Add the State Building Code Division <br /> Surchar�e to each permit. _�^Xp��=b x .0005 $ ��,�_ <br /> or �.50, whichever is greater (contract price) <br /> 3. PostaQe and Handlina (Only mail-in applications) � <br /> 1.50 <br /> 4. TOTAL PERNIIT FEE (Add lines 1-3 above) � Ib5•S� <br /> * CONTR�'�CT PRICE or JOB COST means che acrual or estimated dollar amount charged for the permitted <br /> work inciuding ma[erials, labor, profit, and other fi�ed costs. It is the �*nount to be charged to the <br /> customer for che work done. If any material, equipment, labor, or installation are furnished by the owner, <br /> tenant or any other party the reasonabie market value of such items must be added to the estimated cost <br /> or contract price for permit fee purposes. In the event that there is a dispute on the amount of the job cost, <br /> the Ciry may request the submission of a signed copy of the actual con�ract. <br /> ** The ST�TE SURCHARGE is .000� oi the contract price under 51,000,000 or 5.50 - whichever is <br /> greacer. For valuations over S1,000,000 call the Departmen[ of Inspec[ional Services for the price. <br /> The undersisned hereby applies to the City for issuance of a Mechanical Permit, agrees to do <br /> all work in strict accordance with the ordinances of the City and the regulations of the Minnesota <br /> State Building Code, an certifies that all statements made on this application are complete, true <br /> and correct. <br /> �ppplicant's SiQnature: <br /> " �-�-� Date: -�2'ci�-e <br /> i � <br /> �,pproved By: <br /> Date: �� <br />