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� <br /> �� 3 <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 /> Wood Stove (s) Franklin, other <br /> Brand Name Model No. <br />�;�;; Mfgr's Min., Clearances, side , rear , min. flue dia. <br />��. Total <br />��. <br /> N?�* VENTILATION <br />�� <br />��:" No. Kitchen Exhaust ducted recirculating cfm <br /> No. Bath Exhaust (must be ducted outside) cfm <br /> No. Other Fans: Locations cfm <br /> Tofal <br />'��` FUEL STORAGE (MUST BE APPROVED BY FIRE MARSHAL) <br /> E�' Installation Removal <br />�" Fuel oil: gallons underground inside outside <br /> � <br />�� LP Gas: gallons <br />��,� <br /> g�; Other Gas opening <br />�' <br />� PERMIT FEE CALCL'LATION <br />� <br />��;; 1. 1.25% of Contract Price* or Minimum Fee ($35.00) � <br /> // JC� •— x .0125 $ / ��� �J,C�o <br /> (contract price) <br /> 2. State Surcharge. ** Add the State Building Code Division � <br /> Surcharge to each permit. ( / �%� - x .0005 $ - � S <br /> (contract price) <br /> or $.50, whichever is greater <br /> 3. Posta�e and Handlin� (Only mail-in applications) $ -�-� <br /> 4. TOTAL PERMIT FEE (Add lines 1-3 above) $ 3 5: S� <br />�: * CONTRACT PRICE or JOB COST means the actual or estimated dollar amount charged for the permitted <br />�'' we_k iac:uding materi�!s, laber, profit, and other fixed costs. It is the amount to be 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 that there is a dispute on the amount of the job cost, <br /> the City may request the submission of a signed copy of the actual contract. <br /> ** The STATE SURCHARGE is .0005 of the contract price under $1,000,000 or $.50 - whichever is <br /> greater. For valuations over $1,000,000 call the Department of Inspectional Services 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 ordinances of the City and the regulations of the Minnesota <br /> State Building Code, and certifies that all statements made on this application are complete, true <br /> and correct. <br /> A licant's Signature: � L,n-� Date: �Z�Z-r 9`� <br /> rr <br /> Approved By: Date: <br />