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09i18i2015 12:32 DITTER INC � 9522494616 N0.932 D04
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<br /> .. ��i��i cjif''„��r1411" W �r' �4����^f���`���,' �����)n ���i �Ho p����. �, � .t .
<br /> Ir � ;�•
<br /> �f 5�D i�-A^'?OQ2 ST�.�I'�S^��4"F[jE, `' `� ,
<br /> ❑ Yes,d�is section ap�lies �
<br /> The repfacement of�12esidenti�l fMturp or���liance that meets�II three of the follawing requirements;
<br /> II. Does nor.req�iire modification to clectricfll nr gas servicc. li
<br /> 3, Hes fl t�C��l eost of$500_p0 or le5s;exch�din�the cost ofthe fixn[re or appliance:3nd I
<br /> ',I 3. Is in,proved,installed or replaced by tl�e homeowr�er or licensed contractor. �
<br /> Skip next section,if tl�is npplies; Cost of Permit $ 15.00 i
<br /> Stace Surcharg� $ 1.00
<br /> Mai!-In�ee(If Appiicable) � 2_00
<br /> ' Tatat Permft Fee �
<br /> A�R11�1,F.'T�'�'i `��A t�,'',�'�', ,''IIG;��G�"1--".•.S� .. I;, .t� '�' �q�'a�Q,�,. ,.�';;.
<br /> If abave does not ap�ly; follow guicleiines below: �i
<br /> I. CO � CT wltlCf. ";s 1.2�9�a of contract price with�(fV[inimum l�ce af��O.Q�) �,
<br /> 00
<br /> ��;5�3�.! �;.o��s� 5fo�3 i
<br /> (comract pricc) (minime�m'550.00)
<br /> 2. STAT�SURCFIATtGE p� �'7 I
<br /> -- - �.���_�x.00OS � c�.,'� '
<br /> (�o„irnet pr�ce> �I
<br /> 3. I�QS'fAGG&I,IANDLING(Only on ivtail-In Applicatio��s) $ 2A� �
<br /> �
<br /> 4. TOTAL 1'�RMIT FCE(Add Lines l-3 Above) � �� �
<br /> � " COI�TRACT PRICC or JOB COST means the ac�u�l or esti,nated dollar an�ount char�ed for tl�e ,
<br /> permitted work including m�cerials,Inbor,profiic,and other fixed costs. It is the r�,,,ounc to be cllarged j
<br /> to ti,e customer for the wo�k done. 1F any marerial, equi�yment,labor or instRllationa ar�fi�mished by '
<br /> t3�e owner, te3��nt or any other p:�rty,the reasonable n�arket value of such items must be add�d to the i
<br /> estimated cost or concraet price !'or permit fee purposes. In the event that there is a dispute on che I
<br /> amount of the job cost, the Ciry may req��est the subinission of a si��ed copy of the actual eontrae�, �
<br /> M�C��Ah1I������#i�,['��1P�"I;�u AT� �-��;�. , �. ' , ;,,; ; ',
<br /> The undersi neci hei�eb a lies to the Cit 1'or issua��ce oF n It��chanical Pern�il, flgrees to do all '
<br /> S Y PF� Y ,
<br /> work in strict accordarrce with the or�iinances nf the City rind the rebulations of the St�te of �I
<br /> Minnesota, and cer�ifies chat �11 StA[0m0nlS madc on this ttnplication ore complete, true and '
<br /> correct. I
<br /> A�plicant's Signature: , 171te� �` Q�6�' �� II
<br /> '� 3 i
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