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, j <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 /> VENTILATION <br /> No. Kitchen Exhaust ducted recirculating cfm <br /> No. Bath Exhaust (must be ducted outside) cfm <br /> No. Other Fans: Locations cfm <br /> Total <br /> FUEL STORAGE (MUS BE APPROVED BY FIRE MARSHAL) <br /> Installation Removal <br /> Fuel oil: gallons underground inside outside <br /> LP Gas: gallons ,. <br /> .'�-. Other i z�o r.�<f .�;,��-, ��� �,.,�=� � /-.i o�� ��:�'�..t' Gas opening <br /> ;' � i_ ��;<< i� �=� G �f <br /> PERMIT FEE CALCULATION <br /> 1. 1.25% of Contract Price* or Minimum Fee ($35.00) <br /> ..� �;. �,_;r :- x .0125 $ <br /> (contract price) <br /> 2. State Surchar� ** Add the State Building Code Division <br /> Surcharge to each permit. x .0005 $ <br /> (contract price) <br /> or $.50, whichever is greater <br /> 3. Posta�e and Handlin� (Only mail-in applications) $ 1.50 <br /> 4. TOTAL PERMIT FEE (Add lines 1-3 above) $ �U� �'� <br /> * CONTRACT PRICE or JOB COST means the actual or estimated dollar amount charged for the pemutted <br /> work including materials, labor, profit, and other fixed cosu. 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 ardinances of the Ciry and the regulations of the Minnesota <br /> State Building Code, and certifies that all statements made on this applic,ation are complete, true <br /> and correct. � ✓�_� i -F�� '` -`i%`� <br /> � ��I �12���� ��� � � ' � Date: �'�/ �� <br /> Applicant s Signature: ti��' ✓ <br /> �; <br /> Approved By: Date: <br />