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� � <br /> WOOD BURNING EOUIPMENT <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 /> VENTILATION <br /> No. Kitchen Elchaust ducted recirculating cfm <br /> No. Bath Elchaust (must be ducted outside) cfm <br /> No. Other Fans: Locations cfm <br /> FLTEL 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) `�!J� �-) S� <br /> �; �, �� Z-� x .0125 $ � <br /> (contract price) <br /> 2. State Surchar�e. "X Add the State Building Code Division ._ _ <br /> Surcharge to each permit. � � U Z� x .0005 $ � , <br /> or $.50, whichever is greater (contract price) <br /> 3. Posta�e and Handling (Only mail-in applications) $ 1.50 <br /> 4. TOTAL PERMIT FEE (Add lines 1-3 above) $ l� � , t <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 charged to the <br /> cusi�:r:er fo:the •,��ork 1ur.e. If a*:y r.�a�e:ial, �qr.ipr.i::n[, 'eaboi�, ur�utuiiatinn are n�mished �y the owne_r, <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 of the City and the regulations of the Minnesota <br /> State Building Code, and�certifies that all statements made on this application are complete, true <br /> and correct. " �'j" / <br /> � ,;�, C �' �- - ,,7, �_ <br /> Applicant s Signature: %�� • ' � <, � � � �� C s� �' <br /> ' ' ! � - �;f/'� Date: �� <br /> °� �-��-�' � <br /> Approved By: �� G Date: 9- i6- r 5 <br />