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05/27/2015 15:32 7635354379 GO�DEN VALLEY HTG PAGE 63/64
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<br /> ❑ Xes,this section applieS
<br /> I The replacement of a��;�ential fixture or appliance t�,at meets all tta�ee of the following requirements:
<br /> 1, e t reyuire modi�catpon to e�ect�pcal or gas service.
<br /> 2. Nas a total cost of$500.00 or less;excluding the cost of the fixture or appliance:and
<br /> i 3. Is improved,installed or replaced by the homeowner or licensed cont�ractor.
<br /> Skip next seetion,if tbis app)ies; Cost of Permit $ 15_06 �
<br /> ' State Surcharge $ 5.00
<br /> � 1v�ai1-I�Fee(If Applicable) $ 2.00
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<br /> I �pta��eTmit Fee S
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<br /> j 1f above dces not apply;follow guidelincs bclow:
<br /> 1. �01V'I'ItAC'T PR10E "is�.25%of co�ttract price with a(Minimum Fee of$50A0)
<br /> � �t���� x.0�25$ (/ "� ���
<br /> � �(wntrac�price) (mIq1R�q�SSD-O�)
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<br /> � 2. STA'TE SURCHARGE
<br /> x•0005 $ �
<br /> (wntract price)
<br /> ' 3. POSTAGE&HANDLING(Only on Mail-In Applicatiorls) $ 2.00
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<br /> � a. '�OTA�.��RMx'�k"��(A,dd L�nes 1-3 Above) $ ��J ,�V
<br /> ■ * CO�1'x'RA.C�' P�C� or JO� COS'I'�no.eans the actua� oz' est�mated dotlar amount charged for the
<br /> I permitted work including materials,labor,profit,and other fixed costs. lt is thc amount to bc chargcd
<br /> � to the customer fflr the work done. If any material,e�uipment, labor or installations are ft�rnished by
<br /> � t�e ovv�e�,te�ant or a�y other party,the�reasonab�e nrxarket value o�'such items must be added to the
<br /> � esti�nated cast or coratract price�or permit fee �urposes. In the event that tk�ere is a dispute on the
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<br /> � &imow7t of the job cost,the City may request the submission of a signed copy of the actual conhact.
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<br /> � '�'�e ut�ders�gtted heKeby app��es to t�ae City for issuance vf a Mechanical Permit, agrees to do all
<br /> work �z� st�riet accordance wiith the ordinances of the City and the regulations of the State of
<br /> Minnesota, and eertifies that al� s tezr�e�ts znade on tk�is appaicatio� aze coz�plete, true and
<br /> I correct. �
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<br /> Applicant's Signatu . � Date: `�
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