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06-21-'16 08:52 FROM- FIRESIQE T-168 P0003/0404 F-667
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<br /> ❑ Yes,this section applies ,
<br /> Thc rcplacomcnt of a Residentiai fixt��re or anpliance that m�ts all three of thc following requirements;
<br /> 1. boes ttot require modifieation ta electricat or gas service. �
<br /> 2. �Tas a t taq t cost of$500.00 or less;cxcludin thc cost of thc fixturt or appliance:and
<br /> 3. fs impraved,installed or replaced by thz homeowner or licensed contractor.
<br /> Skip next section,if this applies; Cost of Permit $ 15.00 ,
<br /> 5tate Surcharge $ 5.00
<br /> Mail-In Fee(Tf Applicable) $,.„,,,?,QQ
<br /> Total Permit�ee $
<br /> ,,-�-•;�__ - �-_ = - �. - - -
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<br /> If above does not apply;follow guidefines below: �
<br /> 1. CONTRACT PRICE • is 1.25%of contract price with a(Minimum Fee of 550.0¢) �
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<br /> J /(.O ��z:.0125;$.:.,�:�<:v..�:''
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<br /> '(cprilYact�rice)` ,(niinimuloi,$50.00)`
<br /> 2. STATE SURCHARCE 3 .C���Y x.Q005!�,$ I � ;
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<br /> (contract,price): '
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<br /> 3. POSTACrE&HAN[7C,IN0(Only on Mail-In Applications) $ ��. '"•: �
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<br /> 4. TOTAL PERMIT FEE(Add Lines 1-3 Above) :S',:,_.:. ,,,,�,_,;;;�-� �
<br /> ■ * CON'Y'�tACT ARICE pr JO� COS'I' mcans thc actual or tstimated dollar amount chargcd for thc �
<br /> pormitted work including matcrials,labor,profit,and other fixed costs. It i3 tt►e amount to be charged `
<br /> to the customor for the work donz. If any materisl,equipment,labor or installations ara furnished by
<br /> the owner,tcnant or any other parry,the reasonable market value of such�tems must be added to the '
<br /> estimated cost or contract price for permit fce purposts. In Che event that thert is a dispute on the i
<br /> �r►ount of tho job cost,thc C9ty may request the submission of a signtd copy of the aetual contract.
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<br /> The undersigned hereby applies to the City for issuanCe of a MochaniCal Permit, agrees to do all j
<br /> �.r+ark 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 /> correc#. �3
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<br /> AppliCaaCs SignaturC: -�' _ Date: �
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