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<br /> Woad stave with flu�
<br /> � Wood comhination or add-on '
<br /> �accory �"ireplace witi� flue ` ` Masonry
<br /> _._ �' �'rrxstandxn� � `
<br /> FacTQry Fireplace (s) � _; • , ,
<br /> Woad Stove (s} �r�lin, other `�
<br /> Brand Name Model Na. .�
<br /> ' , Mfgr's Min., Cleazances, sldr:��. Le�' ' , znin. flue dza.
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<br /> No. Kxtche:n Exlaaust .�-?s'�du _
<br /> - Bar,h �?chaust (��ust'�be ducred �iitside) �-`3D c�
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<br /> No ' Oth�r Fans Locatitiz�s
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<br /> �� �CTEL•gT �tA�E (t�fUST`B� APPR�VED � _ , .
<br /> Removai '" = ,w� � . ,�,� � ,�� �x � ., � ,J
<br /> "' �'' '.Tnsta�lati�n � � � -� ; `'� �, , �
<br /> `Y i�sidc ' outsidc. '
<br /> ga�lons',F��' ' ut�dergzaunc�
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<br /> ���+r�:'�3215: �'d1�01]S: . �Vl v �TJ�-�-
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<br /> .,��� , � A ��� � � . . . � _ � . . . ' � � ���i�'-�' � .
<br /> � PERM.TT FEE`�� U T� ; ''- :
<br /> J 1 1 2�% Qf C�ntract �rice� or M�r�rruvm �+ee ,'3�. U ��
<br /> _
<br /> ; � ,��� - . . - �'l�t.�`���. - �.�_
<br /> �c 0125 $ ����`
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<br /> "it°���" ., ;; �' r��{Y/�IlIidCL�r�fl���''� � _'h�S'-3-n_a� 1 _
<br /> T��, � '�v .State1 Su char e �'**�Add:tl�e Statc Building�Codep1vLsion�"-� ` ���. �
<br /> , :_ .rc � . � ,Y-;� . �. � OQQ5 $ �•
<br /> ��, T Surchai ge�Lo e�ch pecmtt � .�„ �`� �- �;;�� ,,,�., ; . .,� ,, M1 - '
<br /> - r �COYI�S3C�i�J1C1��.��r'v� �,:e
<br /> l�, : � � ,
<br /> ar �.50, whichever is gre,s.iter , . . _ ;$
<br /> r�-.—a'
<br /> 3 �-�� Po ta�e and Handl� (Qnly �ail-i� a�pl�cations) � � ,
<br /> � 4, TOTAL P�R.M[T FEE {Add Ii.n�s 1-3 ahove)
<br /> � * CONTR.ACT PRICE or JOS CC�ST means the��1 or est.zmated d°llar aznouut charged itor the perm,itte.d
<br /> work including mat�rials, Iabor, profzc, and other,,�ized casts. '�c is t�c amvunc �o �� c�arged io c�� " `
<br /> •' � customer for the work done. ' If any mate�zal, ecluiPment, labox,az instailation are iurnish�d by tL1�owner, , , ,
<br /> , tenant or auy other Par�Y �e xeas�nak�le market value of such items.musi be�added to ihe estimated cost
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<br /> or Co�tract price for permit fee purposes. In the event�ac[here is a dispute on che aznounc or'the job cast,
<br /> the Ciry uiay request the submission af a signcd copY of_the actual GontraCt.
<br /> �� The STA7E SURCHARG� is .OU(�5 of th� contract price under $1,00(),000 or $.Sa - whichever is
<br /> '�� greater. Far valuations over $1,QQ0,044 ��j �e D�i����m� °£���tional Serviees for the price.
<br /> �'1'���uxtdersigned hexeby applies to t�ie City �ar issuance of a Mecha.nical perrnit, agre�S to do
<br /> ��" �`'aII work in strict accordance with rhe ordi�nces.af the City and#be xegulations of t�e Mts�nesata
<br /> � State$uilding Code, and ceztif"ies that all statements rt�ade on ttus ap�licatian.are comp�ete, t.n�e
<br /> -and correct. '
<br /> ,,: � �
<br /> � AFI?Licant's Signature: f - Date: l- -
<br /> y, ,: - Date: //-/g • �`�
<br /> ,,��Proved By:
<br />
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