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, <br /> '� <br /> $�I��I� ���1iNG EQ�.�'Ii�+N�' • <br /> Wood stove with flue <br /> �Toad cambination or add-on <br /> Pactory fueplace with flue <br /> Factory �ireplace (s) Freesianding i�Iasonry <br /> W'ood Stove (s j �'ranklin, other <br /> Bra�d Name ?Vlodel No. <br /> Ivifgr's Min., Clearances, side , rear , rnin. flue dia. <br /> Tot.�T <br /> �l\'�'I�.A�'I�3N <br /> No. Kitchen Exhaust dueteii recirculating cfm <br /> No. �arh Exhaust (must be ducted outsic'te) cfrn <br /> N�. Othe: Fans: I.ocations cfrn <br /> T�taY <br /> FLT�I., ST�RA�E (MUST BE A..PPROVE� �Y FIR.E MARSHAL) <br /> Installation Removal <br /> Fuel oil: gallans undergraund inside outside <br /> LP Gas: � gallons <br /> Other Gas opening <br /> �'��.�I�` �� C�.I,CLTL.�i I�i°� <br /> 2. 1.25% of Cortract Frice* or I1�Si��:�aa:� F�� ��3j.D�) <br /> � IG, 3� � x .0125 � 12Y� � � S <br /> (contract price) <br /> 2. �tate Surchar�e. ** Add the State Buildin� Code Division <br /> Surchar�e to each permit. $ !�, 3v � x .0005 $ S ► 5 <br /> � � � (contract pricej �� � <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) $ I 3S , S �% <br /> * CONTRACT PRICE or JOB COST means the actual or estimated dollar amount charged for the permitted <br /> work including materials, labor, profit, and other fixed costs. It is the amount to be charge� to the <br /> customer for the work done. If any material, equipment, labor, or installation aze fumished by the owner, <br /> tenant or any orher party the reasonable market value oi such items must be added to the estimated cost <br /> or contract price for germit fee purposes. In the�vent that theze is a dispute on the amount of the job cost, <br /> the Ciry may request the submission of a signed copy of the a�mal contract. <br /> ** The STATE SURCHA.RGE is .00JS of the contract price under �I,Oa0,000 or $.50 - whichever is <br /> greater. For vaivations over $1,000,000 call the Department of Inspectional Szrvices ior the price. <br /> The undersigned hereby applies to the City foz issuance of a �✓lecnanical Permit, agrees to do <br /> a11 �vork in strict accordance with the ordinanc�s of ihe ��ty and the regulations of the Miruiesata <br /> State Building Code, and certifies that all statements made on this application are complete, trse <br /> and correct. <br /> � <br /> Appiicant's�ignature: G�Y r�,� c> ���/`��C� I3ate: � �`t I o S� <br /> �-�, <br /> Ap�roved By: I�ate: <br />