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�VOOD BL'R1�G EQUIP�TE�1T <br /> `Vood stove with flue <br /> �ood combination or add-on <br /> Factory fireplace with flue Maso <br /> Factory Fireplace (s) Freestanding �' <br /> �Vood Stove (s) Franklin, other <br /> Brand Name Model No. <br /> N1f�r's �iin., Clearances, side , <br /> rear , min- flue dia. <br /> VENTIL�TION recirculating cfrn <br /> �o. Kitchen Exhaust ducted <br /> No. �j 4 \ Bath Exhaust (must be ducted outside) �� cfm <br /> �o_ Other Fans: Locations <br /> ��� �,�-vb��_ c��-��. , <br /> FLTEL STO�GE (MUST BE APPRO�ED BY FIRE MARSHAL) <br /> Installation Removal <br /> Fuel oil: gallons underground inside outside <br /> LP Gas: �allons <br /> Other Gas openin� <br /> PER1l�1IT FEE CAI.CULATION <br /> 1. 1.2�o of Contract Price* or Minimum Fee ($35.001 r- n 0 <br /> 1'� t��� <<�� _ x .0125 $ I � � � <br /> (contract pr.ce) <br /> 2. State Surchar�e. ** Add the State Buildin� Code Division � <br /> Surcharge to each permit. x .000� $ � � <br /> or S.�O, whichever is greater (contract price) <br /> (Only mail-in applications) $ 1.50 <br /> 3, PostaQe and Handiina r- <br /> 4, TOT�I. PERMIT FEE (Add lines 1-3 above) � � � � - <br /> � COtiTRACT PRICE or JOB COST means the acrual or estimated dollar amount charged for the permitted <br /> wor�: includin; ma[erials, labor, profit, and other fixed costs. It is the amounc to be charged to the <br /> cuscomer for the work dor_e. If any material, equipment, labor, or installation are furnished by the owner, <br /> tenanc or any other p��feee�on�abes. In the event thatstheret s�dmpute on the amount of the job costt <br /> or concract pnce for p P IP <br /> the City may request the submission of a signed copy of the actuai concract. <br /> ** 'I1;e ST:�F�E S�Rat ons overlS1,000�000 callcthetDepartmentnoferL:spe00ona1�Services �for he pnceer is <br /> �re�cer. <br /> The undersianed hereby applies to the City for issuance of a �Sechanical Permit, agrees to do <br /> all work in strict accordance with the ordinances of the City and the regulations of the Minnesota <br /> State Buildin� Code, and certifies that all statements made on this application are complete, tnie <br /> and correct. <br /> � Date: -'�' � <br /> Applicant's Si4nature: . <br /> �-� Date: � ' 13^ �-� <br /> flrrroved By: <br />