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11/12/2013 12:55 7635354379 GOLDEN VALLEY HTG PAGE 03/04 <br /> • , " , <br /> PEt�M�'I':PEL;�:E►,L��JI::A; ,' <br /> .. , ;: �:�`°���...:�.' . <br /> � ;.8�1S�I�:�4�'�''.=.:��2:'5��,� �'�'v! , <br /> .�~�`' �.:;: <br /> ❑ Yes,this section applits <br /> The replacement of a Reside tial fixture 'gn�e that meets all'three of the folJowing reqairemenis: <br /> 1. Dce$,not require n,odification co electrical or�as service. <br /> ?. Has a total cost of$500.00 or tess;excludine the eost of ihe fixture or appliance:and <br /> 3. !s improved, installed or replaced by the homeowi2e�or(ieensed contractor. <br /> Skip next section,if this applies; Cost of Permit $ I5.00 <br /> StaEe Surcharge $ ,S_00 <br /> Mail-In Fee(lfAppiicabte) $ ''.QO <br /> Tot�l Permit Fee $ <br /> .. . <br /> -:.; .� : � >.;:� :. .�Et��r.k��cALc�'�c�':s 1;r��s;i3:;::.��5�q.ov. ; <br /> If above does noc apply:follow guidelir►es below: <br /> 1. OIVT RIC '�is 1_?5%of contract priee with a(Minimum Fee af�50.00) <br /> 1 ��oo °� X.o�.s$ a�1.5c� � <br /> (Cor1t M pri��) (minimum 540.WJ <br /> 2. T�SURC1,iARGE �q p� G� J'� <br /> � U�V a.0005 $. 1 � l- <br /> (conVuct �cc1 --•-•- <br /> 3. POSTAGE&�IANDLiNG(On1y on Mail-ln Applications) $ 2.Op <br /> a. TO'fAL P��tMIT FEE(Add Lines 1-3 Above) $��` iCIV <br /> • * CONTRACT PRICE or JOB COST mcans the actual or esti�nated dollar amount ehar�+ed Mr the <br /> permitted work intluding materi�ls,labor,prvfit,and other fixed eosts. It is the amount to be charged: <br /> to the customer for the work done. If�y material,equipment,labor or instslEations are furnished b�'� <br /> the owner,tenant or sny other patty,thc reasonable markec value of such iten�s must be added tn tl�ei <br /> estimated cost or cantract price for permit �"ee purposes� In thc cvent that there is a dispute on thc <br /> amount of the job cosr,the City may request the submission of a sig�ed copy of the aetual contract. <br /> . . .;.;. .. , <br /> . <br /> . .�:.� � �e�a�.: ��;L P���r�� ��-��i��� <br /> =a. ��i�rir <br /> The undersigned hereby applies to the City f�r issuance of a Mechanical Permit,agrees to do all! <br /> .vork in strict accordance with thc vrdinances of the City and the regulations of the State of': <br /> Minnesota, and certifies that all statements made on this application are camplete. true �ind; <br /> correct. <br /> i <br /> Applicant`s Signat�kre:� _� l Date: � 1 � � / <br /> f�seE Fdrm <br /> 3 <br /> I <br />