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� <br /> `VOOD BURti�G EQLJ�I�LEN'I' <br /> `Vood stove wirh flue <br /> �/ood combination or add-on <br /> Factory fireplace with flue <br /> Factory Fireplace (s) Freestandin� Masonry <br /> �Iood Stove (s) Franklin, other <br /> Brand Name Model No. <br /> Mfar's l�iin., Clearances, side , rear , min• flue dia. <br /> VENTIL�TION <br /> No. � Kitchen Exhaust � ducted recirculatin� cfm <br /> �o_ � Bath Exhaust (must be ducted outside) �� cfm <br /> �,ro _�_ t?ther Fans: Locations -� �< <br /> FUEL STOR�GE (i�1UST BE APPROVED BY FIRE MARSHAL) <br /> Installation Removal <br /> Fuel oil: �allons underground inside outside <br /> LP Gas: �allons <br /> Other Gas opening <br /> PER'VIIT FEE C�LCULATION <br /> 1. 1.25�'o of Contract Price�` or Minimum Fee (�35.00)x .0125 � �� % <br /> S ��, rrr <br /> (contrac� price) <br /> ? State Surcharae._ ** Add the State Buildin; Code Division <br /> Surchar�e to each permit. j'� ��n- x .000� � � <br /> �"� <br /> or 5.�0, whichever is greater (contract price) <br /> $ 1.50 <br /> 3, Postaae and Handlina (Only mail-in applications) ,l^ <br /> 4, TOTAI. PERi'v1IT FEE (Add lines 1-3 above) � �`��� � ' <br /> * CONTRACT PRICE or JOB COST means the acrual or estima[ed dollar amount charged for the permitted <br /> work iacludin� ma[erials, iaoor, p.oft, and o�e: �eed cests. It is the amount to be charged to the <br /> customer ior the work done. If:ny material, equipment, labor, or installation are fumished by the owner, <br /> tenan� or any other party the reasonable market value of such items must be addea to �ue es[imated cosc <br /> or concract price for permit fee purposes. In the event that there is a dispute on the amount of the job cost, <br /> the Ci[y may request the submission of a signed copy of the actual contract. <br /> ** �:e ST:�TE SURCHrj.RGE is .000� oi the contract price under 51,000,000 or 5.50 - whichever is <br /> �reace:. For valuations over S1,000,000 call che Deoartmen[ of L;spectional Services for the price. <br /> The undersi�ned hereby applies to the City for issuance of a �iechanical Permit, agrees to do <br /> all work in strict accordance with the ordinances of the Ciry and the regulations of the Minnesota <br /> State Buildi.n� Code, and certifies that all statements made on this application are complete, tnie <br /> and correct. , <br /> Applicant's Sianature: <br /> Date: �'�"�"�'C) <br /> Approved By: <br /> Date: � ` 2��� <br />