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9529331869 15:10:47 02-05-2015 4/4 ' � PERMIT�EE CAI:CULATIQN(S) .: BASED OFF:-2002 STATE STATUE` � ❑ Yes,this section appties The replacement of a Re.cidential fixture or appliance tliat meets all three of the following requirements: 1. s not require modification to electrical or gas service. 2. Has a ot t c s of$500.00 or]ess;excludine the cost of the fixture or appliance:and 3. ]s improved,installed or replaced by the homeowner or licensed contractor. Skip next section,if this applies; Cost of Permit $ I5.00 State Surcharge $ 5•00 Mail-In Fee(If Applicable) $ 2.00 Total Pcrmit Fee $ PERiVlIT';EEE CALCULA:TION S —rOBS OV:.ER$500.04 > If above does not apply;follow guidelines below: I. CONTRACT PRICE *is 1.25%of contract price with a(Minimum Fee of$50.00) 2,50�.C1� x.oi2s$ 50.00 (ttmlruct pricc) (minimum 550.00) 2. STATESURCHARGE �t VD 2,�JQ7.(� x.4005 $ I• 25 (contract price) 3. POSTAGE&HANDLING(Only on Mail-In Applications) $ 2.00 4. TOTAL PERMIT FEE(Add Lines 1-3 Above) $ �•Z�J • * CONTRACI' PRICE or JO$ COST means ihe actual or estimated dollar amount charged for the permitted work including materials,labor,profit,and other fixed costs. It is the amount ro be charged to the customer for the work done. tf any material,equipment,labor or installations aze fumished by the owner,tenant or any other party,the reasonable market value of such items must be added to the estimated cost or contract price for permit fee purposes. In the event that there is a dispute on the amount of the job cost,the City may reyuest the submission of a signed copy of the actual contract. MECHArTIGAL PERMiT`APPLIGATTON AGREEMEI�T The undersigned hereby applies to the City for issuance of a Mechanical Permit,agrees to do all work in strict accordance with the ordinances of the City and the regulations of the State of Minnesota, and certifies tttat all statements made on this application are complete, true and correct. Applicant's Signature: �.r'C�� Date: ��05�20�$� 3