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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 ducted recirculating cfm <br /> �o, Ba:h Exhaust (must �e �ucted outsi�?) cfm <br /> No, Other Fans: Locations �� <br /> . Total <br /> FLJEL 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 /> �;,I� i `5��, ��.Z; x .0125 $ _�� y <br /> � (contract price) <br /> 2. State Surchar�, ** Add the State Bu�tldin� �9s�e.Divisi�a �„ <br /> C_��-� <br /> Surcharge to each permit. -� ��' �:^,;��`' x .Q�� $ �. <br /> (contract price) � <br /> or �.50, whichever is greater <br /> 3. Posta�e and Handlin� (Only mail-in appiicati�nsj $ 1.50_____ <br /> 4. TOTAL PERMIT FEE (Add lines 1-3 above) $ ��`_'}• �`� <br /> * CONTRACT PRICE or JOB COST means the actual or estimated dollar amount charged for the pemutted <br /> work including materials, labor, profit, and other fixed costs. It is the amount to be charged to the <br /> customer for the work done. If any material, equipment, labor,or installation are furnished 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 pemut 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 contract price under $1,000,000 or $.50 - whichever is <br /> greater. For valuations over $1,000,000 call the Department of Inspectional Services for the price. <br /> The undersigned hereby applies to the City for issuance of a Mechanical Permit, agrees to do <br /> all work in strict accordance with the ordinances oi the�iry and ine reguiations cf the�S�esou. <br /> State Building Code, and certifies that all statements made on this application are complete, true <br /> and conect. �--__, <br /> . , , <br /> �. _� ,, <br /> � <br /> � � Date: f - -' - ���1 <br /> , � � <br /> Applicant's Signa '��- �--�Z� <br /> Approved By: � Date: <br />