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Mar 10 2015 10: 57RM HP LRSERJET FRX page 4 <br /> �nS}a,l,� �u.ma��, �41C, duC�wor6t � �RV <br /> Ven� G�) Ki k.hevl e+�1�e-u.sF.�3oo c.�'rr+, Ct� d ry�+''�C3� b�+ �o.n-s ' <br /> �C���A.b) sa5 �61�85 '�b: MC�1r1� �W'r1ArG� W O u�E+�' �1�'�''r I�Y�E I", ��X 1�F� 't'�'r 1�P�Q C G <br /> ❑ Yes,this section applies <br /> The replacement of a Residential fixture oc annlian�e that meets all three of the following requirements; <br /> 1. s ot require modification W electrical or gas service. <br /> 2. Has a total cost of$500.00 or less;ex ludin the coat of the fixture or appliance: and <br /> 3, Is improved,installed or replaccd by the homeowner or licensed contractor. <br /> Skip next section,if this applies; Cost of Permit $ 15.00 <br /> State Surcharge $ 5.00 <br /> Mail-In Fee(If Applicable) S Z,00 <br /> Total Permit Fee $ <br /> If above does not apply;follow guidelines below: <br /> 1. CONTRACT PRICE �is 1.25%of contract price with a(Minimam Fee of 550.00) <br /> � l0 f'Jr .DO x.0125$ l �l.2s <br /> (contract price) (mieimum 550.00) <br /> 2. STATE SURCHARGE <br /> x.0005 $ S•2 J� <br /> (oon�act price) <br /> 3. POSTAGE&HANdLING(Only on Mail-(n Applications) $ 2.00 <br /> 4. TOTAL PERMTT kEE(Add Lines l-3 Above) � �3�.J�� <br /> • " CONTRACT PR10E or JOB COS'T ra¢ans the actual or estimated dollaz amount charged for the <br /> pernutted work including materials,labor,;profit,aad other fixed costs. It is the amount to be charged <br /> to the customer for the work done. If any material,equipment, labor or installations ara'fumished by <br /> the owner,tenant or any other party,the reasonable market value of such items must be added to the <br /> estimated cost or contract price far permyt fee purposes. In the event that t3�ere is a dispute on the <br /> amount af the job cast, the City may request the submission of a signed copy of the acdxal contract. <br /> The undersigned hereby applies to the City for issuance of a Mechanical Permit, agrees.to do all <br /> work in strict accordance with the ordin�nees of the City and the regulations af the State of <br /> Minnesota, and certifies that all statements made on this application are complete, true and <br /> correct. <br /> Applicant's Signature: ��lYt.l� Date: .3-�D-2�/Jr <br /> 3 <br />