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WO�D BURNING EQUI�N�NT_ <br /> Wood stove wxxh flue <br /> Wood combination or add-on <br /> F�ctory fireplace witti flue <br /> Factozy Fueplacc (s) __ _ Freestanding Masonry <br /> Wood Stav� {s) �rankain, other <br /> Brand Name Model�tu. <br /> Mfgr's Miz�.� Clcarances, side , rear , n�.in, fluc dia. � <br /> Total <br /> VENT�.ATICIN <br /> Pdo, ^ Kitchet� Exhaust ducted recirculati.ng cfm <br /> Nn. �ath Ex�laust (must be ducted nutsidc) clm <br /> No. Othcr Fans: I ncations cftn <br /> � Total <br /> F�7E.i_. Sx'QRAGE {MUST B� APPRQVEI7 RY FIR� 1VIARSHAL) <br /> Installation �( Reuiuvai <br /> � � Fuel oil: !�e gallons � under�round u�siclG outside <br /> LP Gas: ga�lons <br /> �� Qthcr G�,��n.e� u���2���t-�-u�n��� ��`�`'�' `� Gas ope�ing <br /> PERMIT k'�E CALCULAT�,,,�1V <br /> 1. 1,2550 of Contract Price* or Minim tr� �'ce ($35.g0) <br /> a�QOD X .o12s $ o� S•0� <br /> (Coniract �rice) <br /> 2. Statc Surchar� '""` Add the State Building Code Division <br /> Surcharge to each �ennit. �� x .(}OOg � � . Q'� <br /> (contract price) <br /> or $.50, whichcvcr is greater <br /> 3. Posta�and Handling (pl�ly mail-in applications) $ 1,50 <br /> 4, T�TAL PERMIT FEE {Add lines 1-3 abave) $ o�?•SO. <br /> * CONTRACT p�ICL or JOB CQST tz�cxus thc actual or estiu�ated do}lar amount charged for the pc:rmitieQ <br /> work �ncIuding materials, tabor, profit, and other fixed easts. It is the amount to be char�ed to the <br /> custonzcr for thc wut'k tlouc. 1f any niaterial, equipment, fabar, or instaliatinn are f'urnished Uy thc:owner, <br /> tcnant or zxiy othor party the reasuuablG market value oP such iie�-ns must be added tu the eskimateci Cost <br /> or contract price for permlt fee purposcs, Tn the event that there is a dispute on the ampunt of the job CaSt, <br /> , the City may rcqucst tt�e subinissian of a signed Cppy of the actual contract. <br /> ** Thc STATE SURCHARGE is .0005 of the contract price under �i,(3C}0,000 or $.5��- whiChevet is <br /> grcaccr. For valuations vver $1,OOO,QQO call the Depaz-tment of Inspeetional Services for the price. <br /> Thc undersigned hereby appiies to the Gity for issuance of a Mechanical Permit, a�rees to do <br /> �►I1 woxk in strict aecorda�nce with the ordina�ees of the City and the regulations of the Minnesota <br /> .3tate Bux�ding Cocic, �nd certifies that all statenients niade on this a�plieation are eamplete, true <br /> f�n�d carrect. <br /> . � <br /> �lpplicant's Signaturc: � � Datc; l -I l <br /> � <br /> E�ppraved By: Date: <br />