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_ � . � <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 sto�e (s) Frankli.n, other � <br /> Brand Name Model No. <br /> Mfgr's Min., Clearances, side , rear , mi.n. flue dia. <br /> Total <br /> VENTILATION <br /> No. Kitchen Exhaust ducted recirculating �� <br /> No. Bat�l EX�lallSt (must be ducted outside) �� <br /> No. � Other Fans: Locaaons �� . <br /> . Total <br /> FUEL STORAGE (MUST BE APPROVED BY FIRE MARSHAI-) <br /> Ins�.allation Removal <br /> Fuel oil: gallons underground i.nside outside <br /> LP Gas: gallons <br /> _� Other �'��'%t�� H���$<=,, >`���'�� �T� � Gas opening <br /> . PERMIT FEE CALCULATION <br /> l. 1.25% of Contract_Price* or Minimum Fee ($35.00) <br /> �s�; c� x .0125 $ ;->St C c' <br /> (contract price) <br /> 2. State Surchar�e. ** Add the State Building Code DiXisio�5 � ,�5�` <br /> Surcharge to each permit. <br /> (contract price) <br /> � or $.50, whichever is greater $ 1.50 <br /> 3. Posta�e and Handlin� (Only mail-in applications) <br /> 4. TOTAL PERMIT FEE (Add lines 1-3 above) � <br /> � .,�,Q,a,���r��rrFy�lf:B C�cTynQans the actual or estimated dollar amount charged for the permitted <br /> work including materials, labor, profit, and other fixed costs. It is cfie amouu� fQ 3e charged"to the <br /> � customer for the work done. If any material, equipment, labor,or installation are furnished by the owner, <br /> tenant or any other party the reasonable market value of such items must be added to the estimated cost <br /> or contract price for permit fee purposes. In the event thac there is a dispute on the amount of the job cost, <br /> the City may reqnest the submission of a signed copY of the actual contract- <br /> ** The STAT'E SURCHARGE is .0005 of the contra�t price under $1,000,000 or �.50 - whichever is <br /> greater. For valuadons over $1,000,000 �all �he DeP�ent of Inspectional $ervices for the price. <br /> The undersigned hereby applies to the City for issuance of a Mechanical Permit, agrees to do <br /> all work in strict accordance with the ordinancxs of the CitY and the regula� � om le�eStrue <br /> State Building Code, and certifies that all statements made on this app P <br /> and correct.---,------ _ : <br /> _ _ . ,_ ..� �;: �-r��' ��� � �,� Date: %G ���'-�s <br /> _ Applicant's Signature' � <br /> � _ _ , Date: <br /> - ApprovedBy: ��- - , <br />