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04/21/2016 15:46 7635354379 GOLDEN VALLEY HTG PAGE 03/04
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<br /> ❑ Yes,this section.applies
<br /> The replacement of a Residential fixture or aRpliance that no,etts all three of the following requi�temtnts:
<br /> I. Does not�uiu�e modifica.tion to elect�nical or gas service_
<br /> 2. Has a mtal cost of$500.00 or less;c c u ' the cost of the fixture or applxaz�ce:and
<br /> 3: Is improved,installed or re�laced by che hozneowner or licensed contractor.
<br /> Skip next section,if this applies; Cost of�ernait � 15.00
<br /> State Stuck►axge $ I.00
<br /> MAiI-In Fee(Zif,Applicabae) $ 2.00
<br /> TotaN Permit Fee �
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<br /> ,If above does not apply;follow guideli�aes below:
<br /> a. CONTRACT PRICE *is 1.25%of contract price with a(Minimnm�'ee o�S50.OU)
<br /> �✓�� • 7�_0125$ r ��
<br /> ����pna) (min4mum 550.00)
<br /> 2. �'1 L�ITF.�'uURC.�uficrlF. /� � �r /
<br /> ^ ���-� X_000s $ " �
<br /> (comract yricc>
<br /> 3. POS�',A,G�&HANDLING(Qnly om N�ail-Tn Appkicacions) $ �gg�
<br /> 4. TOTAL�EI.tJ.V�T FEE(Add Lin�es 1-3 Above) $ r
<br /> � ` CO�1'CRAC'T PRICE or JOB CaST means the actua] ox estimated dollar annount ck�arged for the
<br /> pecxnitted w�ork including z�aaterials,labor,pro�E'it,amd other fixed costs. It is the anr�ou�at Fo be chazged
<br /> to the custoaonor for the work done. Zf smy rnaterial, equi�me�pt,labot'or 'vastallations are furraisk�ed by
<br /> the awner, tenant o�c suy other psrty,the�easonable msrlcet value of suckt ite�s tnust bc added to the �
<br /> estYmated cost oc co�ntract priee for pezanit fee �urposes_ In the even,t that there is a dispute on the
<br /> amount of t�,e job aost, thc City znay request thc sub�.ission of a signed eopy o;F tl�e actual contract
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<br /> Tlae undersig�ned k�e�reby applies to t�ie Ciry for issuance of a Meehanical Perr�,it, agrees to do all
<br /> woxk iu� strict acco�ee with the ozd:unances of the C�ty aud the regulations of thc State of
<br /> Miautesota, az�d eertifies that a�� statements made o� this application are caz►a�lete, true and
<br /> correct.
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<br /> .A,pplicant's signatu�e: � Date:
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