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� <br /> t • <br /> ��OD �LT�.I�IIl�T� �C�L�'�i�I4"I' ,- <br /> Wood stove with flue • <br /> Wood combination or add-on � <br /> �actory fueplace with flue <br /> Factory �ireplace (s) �reesianding �Iasonry <br /> W'ood Stove (s) rrank:in, other <br /> Brand Name ModelNo. <br /> Nlfgr's Min., �Iearances, side , rear , min. flue dia. <br /> Total <br /> �1�'T'II.AT�ON <br /> I�lo. Kitchen Exhaust ducted recirculating cfm <br /> No. �3ath Exhaust (must be ducted outside) cfm <br /> IVTo. Othe: Fans: Location� cfsn <br /> 'I'otal <br /> �I. S'�"�RAGE (MUST �E APPROVED BY FII-�E M.A.RSHAL) <br /> Znstallation Removal <br /> Fuel oil: gallon� undergraund inside outside <br /> LP Gas: � gallons <br /> Other Gas opening <br /> ���I'�` k�� C�S.I.,�tTLA�'It3� <br /> l. 1.25% of Cor.tract Price* or I1��rir�um Fe� {�3�.0�) <br /> Sc��-i� _ �U x .0125 � �, �3 - b � <br /> (contract price) <br /> 2. �tate Surchar�e. ** Add the State Building Code Division <br /> Surchar�e to each permif. �oy�. o c� x .0005 $ Z S �Z <br /> (contract price) <br /> or $.50, whichever is greater <br /> 3. . Posta�e and HandlinQ (Only mail-in applications) $ 1.5� <br /> 4. TOTAL PERIlrIIT FEE (Add lines 1-3 above) $ fo � • I I <br /> * CONTRA�T PRICE or 70B CQST means the actual or estimate.�l dollar amount charged for the permztted <br /> work including materials, labor, pmfit, and other fixed costs. It is the amount to be charge� to the <br /> customer for the work done. If any material, equipment, labor, or installation are furnished by the owner, <br /> tenant or any orher par[y the reasonabie market value of such items must be added to the estimated cost <br /> or contract price for permit fee purposes. In the event that there is a dispute on the amount of the job cost, <br /> the Ciry may request the submission of a signed copy of the actual contract. <br /> ** The STATE SURCHA.RGE is .0005 of the contract price under $1,000,000 or $.50 - whichever is <br /> greater. For valuations over $1,Q00,000 call the Department of Inspectional Services ior the price. <br /> The undersigned hereby app�ies to the City for issuance ot a Mechanical Permit, agrees to do <br /> all work in strict accordance with the ordinances of the City and the regulations of the Minnesota <br /> State Building Code, and certifes that all statements made on this application are complete, tnie <br /> and correct. <br /> �4g�iicant's�ignature�� " C�� i�ate: � ZS G <br /> ��� <br /> t�pt�roved�y: �ate: <br />