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05-21-' 15 15:33 FROM- T-837 P0003/0004 F-018
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<br /> ❑ Yes,this sectian applics
<br /> Thc repiacement of a Residential fixture or appliance ihat meets aU three of thc following requiremenCs:
<br /> l. Does not requirc moditication to elecfrical Or g&s serviCe.
<br /> 2. Has a tot�l cost of$500,00 or less;zxcludin�the cost of the fixture or appliancc:and
<br /> 3. Ys improved,installed or replaced by the homeowner or licnnsed eontraetor,
<br /> Skip nexr sectioc►,if this�ppl'res; Cost of Nermit � 15.Q0
<br /> State Surchargc $ 5.00
<br /> Mai!-in Fee(If Applicable) $ 2.00
<br /> 7'otal Permit Fee $
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<br /> ' r,, x y{-�1�F�� � (�j1I{/� .f`{T �� (/ \ �y1 (1 .( �y��( .,*�5 5 /1�1
<br /> �.L�yNfrw�l'�=�\�4KI��y\I.h�l�.���•I.:f-/IN��i�.K.Y.... J.{',LAI.�'JJ,�\�/�,F'��J.��Vt��k-r.)n`Y�✓oY�oo.��` 4�C. ) . :�l
<br /> ..�.... �
<br /> If above does not apply;follow guidelines below: �
<br /> I. CONTRACT PRIC� '� is 1,Z5%of contract price with a(Minimum�'ee oP$50.00)
<br /> 2690.00 " ' t„�• p -. � �°
<br /> a;�� q :s�� ���;�n
<br /> �.. ��'`G4���$' ^t� .���,- '� �
<br /> �(�[��� tiCQZ ��l��l!�Q�1!4�1��a����
<br /> z. s7�a►T�st��zc�a�r� �
<br /> 2690.00 x�'QQR�g,�'$7 1.35
<br /> —;�-�:,�..�.�:.���� .
<br /> ,(�tt.n,tsac��). )
<br /> 3. POS7�AGF�HANDLII�G(Only on Mail-In Applic[itions} :$; >2 00 ' ''('�
<br /> ,
<br /> 4, 1`OTAY.��T2MyT���(Add l.ines ]-3 Above) '$��`.: �`'-�� °u5' '
<br /> ■ '° CONTRACT PRICE or J0� COST me�ns the actual or estimated dollar amount charged for the '
<br /> permitted work ineluding materials, labo��>profit,and other fixed costs. lt is the amount to be charged
<br /> to fhe Gustomer for the work donc. If:�n�material,equipment, labor or installations are ftirnished by
<br /> thc owncr, tcnant or any ofher parry,the reasonable market value of such iterris must be added to thc
<br /> estimated cost or contract pr'rce for nermit fee purposes. rn the event that tliere is a dispute on the
<br /> arnount of the job eost,the Ciry may request the submission of a signed copy of the actual contract. ;
<br /> {`4.`l/AY�"�'.�e.Q�.�tl�T�d�,B��:RTd� �MMa�:��. qN . C"�/ -� � ��f�Yy� ��M'T'iH�l,l�r%r11I I �i:�,i�, C�.vj' .
<br /> . Irt,.P a, t. a ,a,
<br /> The undersignecl hereby applies to the C'rty for issuance of a Medianical Pennit,agrees to do all '
<br /> WOrk in strict accorc�ance with the ordinances of the City and the regulations of the State of
<br /> Minnesota, and certifies that al! statemcnts made on this application ara con,plete, truc and �
<br /> coiTect. �
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<br /> Applicant's Signature: ������ ;17at�;-`- 5/21/15
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