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_ ,��v� � 61z4730510 OS/07/9b 09:40 � :03/03 N0:833 <br /> ��df��lS•s.a F�,� �5..[i, L��V L�'��✓� <br /> 1. 1,25°� of �r �t r'�e* �r ]�ii _ ' <br /> ,'�'��.5 � ���� . x .0125 $ _.L7.�..�.L�.� <br /> (cantract price) <br /> 2, t S�r�har�e. ** Aa�l tt» Statc �uiidi� Ccxte �7ivisio�� � � <br /> Surcharge to each perr��it. �� i r�� Ud x .Q40S $ � � � <br /> (cnntra�t pricc} <br /> ar $.50, whicher+er is greatcr <br /> 3, P�s� g,e �nd l���dli��g (Only mail-in �pplicatiuns) $ 1.SQ <br /> 4. TOTAI� FFRMI`1' I;E� (Add lines 1-3 above) $ /,s(�, , ;�� <br /> '" GL7NTRA�T PRICG or JUB COS'C tnetu�s ihe t�ctual or estimated dollar an�ouut ch�rged for the pernutted <br /> work including matcri;ils, tabar, prc�iit, atrd other fixed casts, tt is tlie a�nount tu b� charged tu lhe <br /> custati�er for the work donc. lf any matcrial, equipmcnt, labar, or inytallati�n arc furnished by the owner, <br /> tcnant vr any other party tlie re�s�nable inu�ket value of such items miast be added ro the estiinated cost <br /> or cvntract price for permit icc purpascs. In thc cvcnt that th�rc is u disputc on Ihe amaunt of the job co�t, <br /> the Ciiy muy reyu�st lhc subaiissic�n of a signed copy of tl�e actual cc�i�tract. <br /> '�* 7'lie 5'1"A'1'L 5URCIJARGE is .0005 af lhe contract price und4r $I,()()0,000 ur $.50 - whichever ix <br /> gre;�tcr. Fcar valuationw aver $1,0OO,OUO call the Deparunent of ]nspectioiiaf Servic�s fpr thc price. <br /> The un�l�r5ignecl hcrcby applics to tl�e City for issuance of a I'tuinbing Permit, agrecs t� do all <br /> wark in �txic:t �ccordancc with the ordinances of thc City and tt�e rcgulations c�f the St�tte �t <br /> Minncscrta, and ccrtifies that all statements I118dC oii this application arc compl�tc�, true ;�nd <br /> correct. <br /> Appticant'sSi�;rtature: _ _ Date: �� � �� <br />