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O1/46/2016 wED 9: 52 FAx 763 �73 8565 Sdbre xe�ting b Air Cond f�007/OQ7 <br /> ❑ Yes,this section applies <br /> The repfacerrtent of a Residential fixtune or annliance that meets all thrcc of ille following requirementS: <br /> �. pOCS i]bt require modificaUan to elech-ical or gas servic.�. <br /> 2. Has a total aost of$5�0.00 or less;exclu ' the cost of the fixture or appliance:and <br /> 3. �s inaproved,installed or r�laced by the homeowner or licensed wi�Gractor. <br /> � Skip next section,if this applies; Cost of 1'eimit � � � � �15.a0 ^ � <br /> Stete Surcharge $ 5•00 <br /> Mail-In Fee(Tf Applicable) T, 2.00 <br /> Totnl�'ermit Fce S <br /> I <br /> i If above does not apply;follow guidelines below: <br /> j1. . CONTRACT P'BICT� *is 1.25%of contract,price with a(1V�inimum l�ee of SS0.00) <br /> ��� ,D(�d x.o125� ��.16��JI� <br /> (contract price) (p�lolmum fi9D.00) <br /> 2. STATE 3URCHARG� /� <br /> I S1ZD.O� x.0005 � "I�D�O <br /> (oonuacc price) <br />� 3. POSTAGE 8t HANDLING(Only an Mail-Tn Applications) S _�4Q <br />� <br /> j 4. TOTAY,P�It1VQT�'FE(Add Liues 1-3 Above) s Z��,•,,.�J,�P „ <br />' ■ '� CONT1tACT PRICL or JOB COS'x'mesns the sctual or estirnaced dotlttr nmount charged for tha <br /> pe,mitted work including materciaLa,labor,pro�t,and other fixed costs. It is the amount to be charged <br /> to the cusUomer for the work done. If any matet'ral,equipment,labos pr;nstallationa are furnished by <br />, the owner,tenant or any other party, the reasonable market value o�such itmns must be added to the <br /> estimated c�st or contract price for permit fee purposes. In the euent that thare es a dispute on the <br /> amount of the job cos�the City may request the submission of a signed copy of the sctual co�act <br /> i <br />� The undersigned hereby applies to the City for issuance o�a Meahanical Pemtit, agroos to do ell <br /> work in strict accordance with the ordinanoos of the City and ttxo ragulations of the State of <br /> ]�iu�nesota, aiad cexta£ies tba� all stataraeuts made on this ap�lioatior� are com�plate, ixua and <br /> correct. � <br /> Applicani's Signature: r���,,V►/ �QUU'�i� Date: �' �i'�+'�J ' <br />, � <br /> I I . <br />� <br />� 3 . <br /> i <br />