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09-28-'16 09:56 FROM- T-163 P0003/0004 F-196
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<br /> ❑ Y�s,this section applies
<br /> The replacement of a Residenti�l fixture or a Ipp iAnce that meets all th,ree of the following requirements_
<br /> 1. Does,�ot require modification to electrical or gas service_
<br /> 2. Has a otal cost of$500.00 or less;excludine the cost oFthe fixture or appliance:and
<br /> 3. Ts improved,installed or replaced by the homeowner or licensed contractor.
<br /> Skip next section,if this applies; Cost of pennit $ 15.00
<br /> Stzte Surcharge $ 5.00
<br /> Mail-Tn Fee(If Applicable) $ 2.00 I
<br /> Total�ermit�ee $ �
<br /> 'p}-�}�� +�t �5 �j�+.Y �c\-�--y--�-T(4-�(�-T�q/,s�-�t� (�(�,--r-� �,y ��r.,1'Y 1 �
<br /> ��"�� `' �(}K�;,�yis`��Y.�Y�1��.iI1 �r� �`�,1:�.� .L*lll,�,? f��71.1'�1'�v��vN4l�V�+�4�.,�y'��llil��,�..b x$iY.ral��x���C'.�Cf�A�'rl �.
<br /> Tf above does not apply;follow gu'rdelines below: ,
<br /> 1. CONTRACT PRICE � is 1.25%of contract price�vith a(IVTu�imum Y�'ee of 550.00) ��
<br /> ,���� , 00 D I
<br /> _ X,o�zs��_.0.°
<br /> (contract price) (minimum 550.00}
<br /> �
<br /> 2. STATE SURCHARGE ���.�
<br /> 3 X.0005 $ 1 :�7 3
<br /> (contract price)
<br /> 3. �OSTAG�c�HANDLING(Only on Mail-In ApplicaTions) � $ �6p ',
<br /> ��
<br /> 4. TO'I'AL PERiVIIT FEE(Add Lines 1-3 Above) $
<br /> ■ 9 CONTRACT PRIC� or JO� COST means the �ctual or estrmated dollar a►nount charged for the
<br /> peimitted�vork ineluding maCerials,labor,profit,and ot}�ex�xed costs. It is the amount to be charged
<br /> to the customer for t��e work done. �f any material,equipment, labor or installations are furnished by
<br /> thd o�vn;eY, tenant or any pther party,the reasonablo mflrket v�lue of SUCh items must be&dded io Llle
<br /> esti�t�ated cost ar contract price for pzrmit fee purposes. In the event thAt there is A dispute on tlle
<br /> amount of the job cost, th� City may request the submission of A signed copy of the aCTu�l contr�Ct.
<br /> ��-;-���,..--r-.�
<br /> t ' '�j^`q�i'rr �U/��-(�(�li T 7�"�F ��(p7���//�JI `1 ,1p�� '(� �1��r/� � �x(� �'��V�' y��S �,A�'".y�!`,�:
<br /> .t'�t�1M.�ll'.�`t7����..��.�.13L a���i�v-'�r[,C�ArV.z��.�.".,;.,`�-/h.�^.{a�1�w���N��A�u�'/����V E. �+71���R�1a")�7.nnJ�.Y1�'��``rt-4'�r/:V�� ��"'f
<br /> 1 ��;,M
<br /> The uiide��signed hereby applies Io the City fpr issuance of a Mechanica!Pennit, agrees to do all
<br /> work in strict accordance with the ordinances of the City �nd the regulations of the State of
<br /> Minnesota, �ad certifies that all statements made on this application are complete, true and
<br /> correct.
<br /> , ��'W"v 1 � ¢�.
<br /> Applicant s Signature: Date_ �U
<br /> 3
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