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, , 0P�22/2014 15:27 7635354379 GOLDEN VALLEY HTG PAGE 03/03
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<br /> ❑ Yes,thi5 section applies
<br /> The replacement of a Resident a �ixture or a that meets a�l three of the following requirements'
<br /> 1. Does not xequ'tre modificatiot7 to eiechical or gas Service.
<br /> 2- FIfls a total cost of$500.00 or less;e cludin the cost of the fixture or appliance:and
<br /> 3. Is improved,installed or z�eplaced by the ho�eowner or licensed contractor.
<br /> Skip nexc section,itFthis applics; Cost of Permit $ 15.00
<br /> State Surchazge $ 5.00
<br /> M�il-In Fee(If Applicable) $ 2,00
<br /> Total Permit k'ee $
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<br /> If above does no2 apply;follow guidelines below:
<br /> 1• �Q]VTRACT P�CCE '�is 1.25°/p of co�ntract price with a{Minitnum Fee of$50.00)
<br /> �
<br /> x.0125$
<br /> (contract price) (rtrinimum 550.00)
<br /> 2, STATE SURCHARGE �. �
<br /> x.0005 $
<br /> (contract prlce)
<br /> 3. POS�AGE&1iANDLING(Only on Mail-ln Applications) $ 2,00
<br /> 4. TO'�'AL PERMIT F��(A,dd Lincs 1-3.A,bove} $ / a, �D
<br /> ■ � CONTRACT PRICE or JO� COST means the actual or estimated dollar amount charged tor thc
<br /> periltitted work including materials, labor,profit,and other�xed eosts. !t is the amount tv bc charged
<br /> to the customer for the work done. If any material,equi�mtnt,3abor or installations are fumished by
<br /> the owner,tenant or at�y ptber party,the�reQsonxble market value of such items�ttust be added to the
<br /> e5timated cost pr eontract price �'or pertnit fee purposes. In the eva�t tbat there is a dispute pq thc
<br /> amount of the job cost, the City may request the submission of a signed copy of the actual contract.
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<br /> � ' Ca4:'T�O�I�;A�:.� .�il1�ENT
<br /> The unders�gned hereby app(ies to the Ciry for issuance of a Mechanical Permit, agrees to do all
<br /> work in strict aceordance with the ordinances of the City and the regufations of the Statc of
<br /> Minr►esota, and certifies that all statements rtaade on this appli�ation are compleee, true and
<br /> correct. �
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<br /> Applicant's Signatur : r � � Date: '
<br /> V�'�t- �.�.5 �� l3� o`�o! 0�
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