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11-15—' 16 14:14 FROM— T-410 P0003/0004 F-501
<br /> • ''X � � �n� � „�.r �\�����R� l� � n �9^��^"`��1V F.l, .�t'Y+r,-�.7 t S�'� ���•'��`�d�.
<br /> i t � 1 i �G i���� Yr.rl� P✓��� ,i; .+ ��.9a��� aR.t �l .'! ff� �s�P�f�: "�`���i � �tadx°�(>�e��'��'T����
<br /> � .� " AS"E�� �1�� O02 7�p � �7"p � � . � � <s � K �
<br /> t, s,�`,'� r�l,�.� ,�.,��Y"���. ' J;l. .'�. '����f.'A.z�i7;��.�:�. '>�'.!,^i ' '/�' �ts:��i.n J� wu,n
<br /> � � v, o n1; 4-;d-Y,r...,. ,».�el...a.,<o,i.i•�.T ,.�,l.1.rJ ,,,\..,.
<br /> ❑ Yes,this section applies
<br /> The replacement of a Residcntial fixture or appliancz t}1�t meets all tliree of the following reqltirements:
<br /> 1. Does not require modifieation to electrical or gas service.
<br /> 2. T�as�total cost of$500.00 or less;exClttdin�the Cost of tho fixture or appli�nCe:and
<br /> 3. Is'rmproved,installed or replaeed by the homeowner or licensed contractor.
<br /> Skip r�ext section,if this applies; Cost ofpermit $ 15.00
<br /> State Surchar�e $ �.00
<br /> Mail-Cn�ee(If Applicable) $ 2A0
<br /> Total�ec�anit�ee $
<br /> �--r---r.�--r ,--� 7� � j�. ,;�..� r {' },'5�/ �,y y� }?�qr}.j� �`(� (�
<br /> 'e i,yi��n. �,� ir � 1���.�+�' �:H , �.i.�?�" ��.1VI��,��v'�•i1,QI3 ;V V..Li\��J.V����(O�l�'�'�°.�'��'n��{j�L{�'i��n����,
<br /> [.> ..�,,.•.r, <, t._, .wa . ,.<.. .i,.,:., t. ��,s,�s�1:7=.x�as:�UvVa �S.t.,1r
<br /> If above does not apply;follow guidelines bolo�v:
<br /> 1. CONTRt1,Cx�XtIC� *is 1.2J%of contract price wiCh x(Minimum�'ee of$50.00)
<br /> pP p
<br /> � �. x.0125$ Q�, �
<br /> cnntract pricc) (mfnimun�550.00)
<br /> . S'X'A.'x�SUI2CHA�2G� �7 p p
<br /> � � � � t
<br /> !i �O O' x.0005 $ .
<br /> '(contract price)
<br /> 3. T'OSTAG�&1�ANb�.TNQ(Onf�on Mail-Iti Applications) $ ,�( ��d�
<br /> 4. TOTAT�p�T2MI'�'���(Add T,ines 1-3 Above) $ ��5' 3 Y
<br /> ■ ^` COi�r'1('�tACT P�tIG� or 70B GOST aneans the actual or estimated doll�r amount charged for the
<br /> pennitted�vork�ncluding materials,labo��,prof"rt,and other fixed costs. It is the amo�mt to bo c},arged
<br /> to the customcr for tht work done. If any material,equiprnent, l�bor or instatlations are fi�rnisl�ed by
<br /> the o�vner,tenant or an�other parry,the reasonable market value of sucla ite�ns m�ist be added to the
<br /> estimated cost or contract price for permit fee purpos�s. In the event that tllere is a dispute on the
<br /> amount of Che job eost, [he City may request tlit submission of a signed co�y of the ac[ufll co�ltract.
<br /> `�b ,;°',''y< ,,� <�!'�� AN�; �.;°�������4������#`T'ZC�;�J�'���._ 1�I`I'xr���:�;;v e,�,��a��s�,�;"
<br /> The undersigned hereby applies to the City for issuance of a Mechanical Permit, agrees to do all
<br /> �vork in strict accordance �vith the ordinan.ces of the City aud the regulations of the State of
<br /> Minnesota, and certifies that a!1 statements rnade on this applicati0n az�e CompleCe, true �nd
<br /> correct.
<br /> Applicant's Signatw•e� y ���✓ Date: L r _1 ��y "�
<br /> 3
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