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, . <br /> WOOD BURNING EQUIPMENT <br /> Wood stove with flue <br /> Wood combination or add-on <br /> Factory fireplace with flue � <br /> Factory Fireplace (s) Freestanding Masonry <br /> Wood Stove (s) Franklin, other <br /> Brand Name Model No. <br /> Mfgr's Min., Clearances, side , rear , min. flue dia. <br /> Total <br /> VENTILATION <br />• No. Kitchen Exhaust ducteii recirculating cfin <br /> No. Bath Exhaust (must be ducted outside) cfm <br /> No. Other Fans: L.acations cfm <br /> , Tp� <br /> FUEL STORAGE (MUST BE APPROVED BY FIRE MARSHAL) <br /> Installation Removal <br /> Fuel oil: gallons underground inside outside <br /> LP Gas: gallons <br /> Other Gas opening <br /> PERMIT FEE CALCULATION <br /> 1. 1.25% of Contract Price* or Minimum Fee ($35.00) � <br /> !—.���o X .ol2s � �j.�� <br /> (contract price) <br /> 2. State Surcharge. ** Add the State Building Code Division , <br /> Surchai•ge to each permit. x .0005 $ 1 <br /> (contract price) <br /> or $.50, whichever is greater <br /> 3. Posta�e and Handlin� (Only mail-in applications) $ 1.50 <br /> 4. TOTAL PERMIT FEE (Add lines 1-3 above) $ e ���y � <br /> * CONTRACT PRICE or JOB COST means the actuat or estimated dollar amount charged for the pemutted <br /> work including materials, labor, profit, and other fiaed costs. It is the amount to be charged to the <br /> customer for the work done. If any material, equipment, labor,or installation are fumished by the owner, <br /> tenant or any other party the reasonable 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 City may request the submission of a signed copy of the actual contract. <br /> ** The STATE SURCHARGE is .0005 of the-eontract price �r $1,000,000 or $.50 - whichever is <br /> greater. For valuations over $1,00 �call the Department of pectional Services for the price. <br /> The undersigned hereby appli to the City for issuance o 'cal Permit, agrees to do <br /> all work in strict accordance ith the ordinances of ity and e re lations of the Minnesota <br /> State Buiiding Code, aII ' s that all,�tate ts made on s app 'cation are complete, true <br /> and correct. � ' "`' � � / <br /> ; - � - " -..� \�� <br /> �__ ; - xl , <br /> / ry � V <br /> Applicant's Signatur % -��� Date: � LJJ <br /> .-� <br /> Approved By: Date: <br />