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, 06/19/2613 01:13PM 7637542908 RIVER CITY PAGE 03/03
<br /> ;: , , `PERMI'T'k'�EE C�1•�.��1.�,A,TIC�N;(�} � , ;
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<br /> ;- ;:BA��D�hF' .�002:�.`LAi�.�s�'�.�'�� ��, „ , .,,
<br /> ❑ Yes.this section applies
<br /> The replacement of a JZesidentiAl fxturc or anpiiancc t)�at mcets xll three o�ihc followin�requirements:
<br /> 1. Does not require modificatio�t 2o electt�ical or gas service.
<br /> 2. Has a coLal cost oF$�00.00 or less;excludin�T the cost of the fistur�or appliance:and
<br /> .i. ls imprpved, installed or rep►aced by the homeowner or fice�sed contractor.
<br /> Skip next 5ection,if this app�ies: Cost of Pennit $ 15.OU
<br /> State Surcharge �__ 3,p�
<br /> i�ai{-In Fee(If Applicable} � 2.00
<br /> Total Pe�mxt F'ee �
<br /> � "n ��' '__�� '-�af��.�'�:�i���. � ' '`.��8�{Q�����ZQ�1� •
<br /> 7y _.
<br /> -='a, ...i �. : d �..2I�� �—_;; �. x'��,a,�, ��:��^r��d[.
<br /> If above.does not apply;follow guidclines below;
<br /> I. cO�v'�'RFtCT ftIC� * is ]_25°0 of contract price with a(Miniuoaun�Fee of$50.04)
<br /> 1 OO .o� X.ot?s� .o[�
<br /> (cvntract price) (mmimum 550.00)
<br /> 2. STATE SU.RCI3ARGE � � . ��
<br /> a . x.000s �
<br /> (contruct pricc) �
<br /> 3. PQSTAGE&HANDLZI�lG(Only on Mail-]n Applicatipns} $ 2,�p
<br /> 4. TOTAx,�RMIT k��(Add Lines a-3 Above) $ � � ' ��
<br /> • * CONTRACT PRICE or JOB COST means t�c actual or estimated dollar anoount charged for rhe
<br /> permitted work iricluda�,g mattrials, Iabor,profit,and other fixed costs. iC is the a�out�t to be charged
<br /> to the Customer for the work done, lf any tnaterial, equipment, labor or installations are �'ut�r►ished by
<br /> the owner,tenant or any othe�parry,t}�e reasonable mnrket vAlue of such items must bc addcd to the
<br /> estiroattd cost or contract price far permit fee purposes. �n the event that There is a dispute on the
<br /> amounc of che job cost, the Clty may re�ttest the submission of a signed oopy o�'t,he aCtual contract.
<br /> ,r��'�: .__k' �..°.�•,��1'�;��C�:>���'+�-�.��.:j��.�s-- ��1,� -�r l4'rrP A,,� ,-�.
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<br /> The undersigr�ed hereby applies to the City for is9uance of a Mechanical pez�at, agrees to do all
<br /> work in strict accordance with the ordinances of the Ciry and the regnlations of the State of
<br /> Minnesota, and certiftes that a�I statemcnts made o;� tllis application are epzxiplete, ITue and
<br /> CozzeCt.
<br /> Applicant'S Signature: ^ Date: c..� 1 T/ ,�
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