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� <br /> �VOOD BURtVING EQL�TPN�NT <br /> Woc�d stove with flue <br /> Wood combination or add-on <br /> Factory fueplace with flue <br /> Factory Fireplace (s} Freestanding Masonry <br /> _ Wood Stove (s) Franklin, other <br /> Br�nd Name Model No. <br /> Mfgr's Min., Clearances, side , rear , min. flue dia. <br /> Total <br /> �IV�'I�ATION <br /> No. Kitchen E�aust ducted recirculating cfm <br /> No. Bath E.xhaust (must be ducted outside) cfm <br /> IVTo. Other Fa.*�s: Locations cfrn <br /> Total <br /> FLTEI, ST�RAGE (MUST BE APPROVED BY FIRE MARSHAL) <br /> Installation Removal <br /> Fuel oiL• gallon.s underground inside outside <br /> LP Gas: � gallons <br /> Other Gas opening <br /> ���1IT' �� Cr�,LCULATI0I�1 <br /> 1. 1.25% of Cor.tract Price* or IVlia�im�e�r� F�� ($35.00) <br /> `t uSS x .0125 $ �L • � � <br /> (contract price) <br /> 2. State Surchar�e. ** Add the State Building Code Division <br /> Surchar�e to each permit. �`1�c.�S S x .0005 $ 2-:�� <br /> (contract price) <br /> or $.50, whichever is greater <br /> 3. Postage and Handlina (Only mail-in applications) $ 1.50 <br /> 4. TOTAL PERMIT FEE (Add lines 1-3 above) $ l��1 • l'o� <br /> * CONTRACT PRICE or J(�T3 COST means the actual or estimaterl dollar amount charged for the perm;tted <br /> work including materials, labor, profit, and other fixed costs. It is the amount to be charged to the <br /> customer for the work done. If any material, equipment, labor, or installation are fumished by the owner, <br /> tenant or any other party the reasonabie market value of such items must be added to the estimated cost <br /> or contract price for permit fee purposes. In the event that there is a dispute on the amount of t$�e job cost, <br /> the Ciry may request the submission of a signed copy of tbe actual contract. <br /> *� The STATE SURCHARGE is .0005 of the contract price under $I,000,000 or $.50 - whichever is <br /> greacer. For valuations over �1,000,000 call the Department of Inspectional Services ior the price. <br /> The undersigned hereby applies to the City for issuance of a Mechan.ical Permit, agrees to do <br /> all work in strict accordance with the ordinances of the Ciry an�the regulations of the Minnesota <br /> State Building Code, and certifies that all statements made on this application are complete, true <br /> a.nd conect. <br /> C� � \ , � � <br /> � 5 Z5�o(�, <br /> Appiicant's Signature: �11�� Date: <br /> ��� <br /> Approved�y: Date: <br />