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4 <br /> FIREPLACES <br /> Gas factory fireplace <br /> Wood burning factory fireplace with flue <br /> Wood Stove <br /> Wood stove with flue <br /> Brand Name Model No. <br /> VENTILATION <br /> No. ( Kitchen Exhaust 1, ducted recirculating /50 cfm <br /> No. Bath Exhaust (must be ducteed outside) cfm <br /> No. l _ Other Fans: Locations�i" /kM ' U/t#1A1.tQ ? cfm <br /> (fret( a Of yosieip <br /> FUEL STORAGE (MUST BE APPROVED BY FIRE MARSHAL) <br /> Installation Removal <br /> Fuel oil: gallons underground inside outside <br /> LP Gas: gallons <br /> Other Gas opening <br /> PERMIT FEE CALCULATION <br /> 1. 1.25% of Contract Price* or Minimum Fee ($35.00) <br /> /Ian C19 x .0125 $ 75150 <br /> (con ract price) <br /> 2. State Surcharge. ** Add the State Building Code Division <br /> Surcharge to each permit. W'{_ x .0005 $ 7.649 <br /> or $.50, whichever is greater (contract price) <br /> 3. Postage and Handling (Only mail-in applications) $ <br /> 4. TOTAL PERMIT FEE (Add lines 1-3 above) $ <br /> * CONTRACT PRICE or JOB COST means the actual or estimated dollar amount charged for the permittee <br /> work including materials,labor,profit, and other fixed costs. It is the amount to be charged to the customer <br /> 111110•••--- for the work done. if any material, equipment, labor, or installation are furnished by the owner, tenant or <br /> any other party the reasonable market value of such items must be added to the estimated cost or contract <br /> price for permit fee purposes. In the event that there is a dispute on the amount of the job cost,the City may <br /> request the submission of a signed copy of the actual contract. 1/sly -RR <br /> e <br /> ** The STATE SURCHARGE is .0005 of the contract price under$1,000,000 or $.50 -whichever isgreater. <br /> 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 all <br /> 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 /> Date:� <br /> Applicant's Signature: I ` ' /�47,0( <br /> Approved By: Date: <br />