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09-16-'15 13:14 FROM- T-263 P0003/0003 F-533
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<br /> ❑ Yes,this section applies
<br /> The replacement of a Residential fixture or appliance that meets all three of the following requirements:
<br /> 1. Does not require modification to electrical or gas service.
<br /> 2. Has a total cost of$500.00 or less;a cl di the cost of the fixture or appliance:and
<br /> 3. Is improved,installed or replaced by the homeowner or licensed contractor.
<br /> Skip next section,if this applies; Cost of Permit $ 15.00
<br /> State Surcharge $ 5.00
<br /> Mail-In Pee(If Applicable) $ 2.00
<br /> Total Permit Fee $ _
<br /> 171,4,k: ::1,:;1,.!..)1
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<br /> R4�: •el��`,:; 'S' ..) yW:01-",!.:$ •yO,c,A .'9_. ('' 4 .�^.!g % �ti: /n� 0, rl Vh/',hµp'r5'�' r {2'�,
<br /> If above does not apply;follow guidelines below:
<br /> 1. CONTRACT PRICE *is 125%of contract price with a(Minimum pee of$50.00)
<br /> Vit;Aa t .Ft �i ' - r s► 59;:1
<br /> 2. STATE SURCHARGE " `n() C I 35
<br /> _---- 1, t ,�`-. . x .990:5, ,„
<br /> 3, POSTAGE&HANDLING(Only on Mail-In Applications) f$;; ;2`Ol);-,+'4.',;.ry'
<br /> 4. TOTAL PERMIT FEE(Add Linos 1-3 Above) f
<br /> ■ * CONTRACT PRICE or JOB COST means the actual or estimated dollar amount charged for the
<br /> permitted work including materials,labor,profit,and other fixed costs. It is the amount to be charged
<br /> to the customer for the work done. If any material,equipment, labor or installations are furnished by
<br /> the owner,tenant or any other party,the reasonable market value of such items must be added to the
<br /> estimated cost or contract price for permit fee purposes. In the event that there is a dispute on the
<br /> amount of the job cost,the City may request the submission of a signed copy of the actual contract.
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<br /> The undersigned hereby applies to the City for issuance of a Mechanical Permit, agrees to do all
<br /> work in strict accordance with the ordinances of'the City and the regulations of the State of
<br /> Minnesota, and certifies that all statements made on this application are complete, true and
<br /> correct.
<br /> / �,�,/ L d ' qh(o/�'
<br /> Applicant's Signature: Unlit/ v step
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