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� . <br /> :.- <br /> . ....._ .._.. . ._ _ . . . _ <br /> WOOD BURNING EQUIPMENT - - _ <br /> . Wood stove with flue . <br /> -.. Wood combination or add-on _ <br /> Factory fireplace with flue � � - <br /> . • Factory Fireplace (s) Freestanding . Masonry � <br /> � " wooa sco�e (s) Franklin, other � <br /> Brand Name Model No. <br /> Mfgr's Min., Clearances, side , rear , min. flue dia. � <br /> .,`'" Total <br /> VENTILATION <br /> No. Kitchen Exhaust ducted recirculati.ng �� <br /> No. Bath Exb.aust (must be ducted outside) �� � <br /> No. Ctil�: Fans: T_:�c•ati�r.s ----- cfm . <br /> _/�,, ( 'rotal� <br /> �b . � `-�'P '��_ R- L� � �-- � ��j <br /> FUEL STORAGE (MUST BE APPRO D BY h�A���-) <br /> Installation Removal <br /> Fuel oil: gallons underground inside outside <br /> Lp Gas: gallons <br /> Other Gas opening <br /> PERMIT FEE CALCULATION <br /> 1. 1.25% of Contract Price* or Minimum Fee ($35.00lX 0125 $ ��C1� U� <br /> ���,D(� <br /> (contrac[ price) <br /> 2. State Surchar�e. ** Add the State Building Code Division ��o <br /> Surcharge to each permit. x .OQOS $ ��`J'� <br /> (contracc price) <br /> � or $.50, whichever is greater $ 1.50 <br /> 3. Posta�e and Handlin� (Only mail-in applications) � ,, /p✓ J� <br /> 4. TOTAL PERNIIT FEE (Add lines 1-3 above) - <br /> * CONTRACT PRICE or JOB COST means the a�rual or estimated dollar amount charged for the permitted <br /> work including materials, labor, profit, and o[her fi�ed cosrs. It is the amount to be charged to the <br /> � customer for the work done. If any material, equipm�nt, Iabvr,or instat�acion��`�Y����� <br /> � tenant or any other party the reasonable market value of such items must be added to the estimated cost <br /> or con[ract price for permit fee purposes. In[he event that there is a dispute on the amount of the job cost, <br /> the Ciry may ier;uest the submission of a signed coPY of[he actual contract- <br /> ** The STATE SURCHARGE is .0005 0�the contract price under $1,Od0,000 or $.50 - whichever is <br /> greater. For valuations over $1,00O,OOo call the DePartment of Inspectional $ervicxs for the price. <br /> The undersigned hereby applies to the City for issuance o�a���ao��t�e M�innesota <br /> all work in strict accordance with the c��emen madle on this applic aon are complete, true <br /> State Building Code, and certifies tha <br /> and correct - .- , ' , <br /> . :. _ .:_ __ - i - � .. . � �� <br /> � <br /> __ . Da �� .l--, <br /> _ Applicant's Signature: � <br /> - _��/ Date: J <br /> - APPro�ea By:: � � <br />