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, , Frqm:COUNTRYSIDE HEATING & COOLING 763 479 2518 03l31/2015 14:36 #035 P.003/003 <br /> .. �.ti F r ��"s ." b�_�.0 : � 4 �,�.'�� � �������'�,� { tF ^'' 3 :� '��... �tr��r�iT^'<<' ��. <br /> �`�. 9 a-�` ���? r `�; .P���t"6$-ns���, . .s,x �`5� .a y�3 1 k �. ��d'�.#"� r t ti �� y��"��z <br /> � .�,..�:.,:a ... ._..}..,i. e� . :�. __..y,.�....#�`„�� „t� �� ,��"'j" <br /> r� r ,« ° <br /> _ _ �t. ;?. i �,v ,r.� <br /> ❑ Yes,this section applies <br /> T'he replacement of a Residentia]fixture or appliance that meets all three of the following requirements; <br /> 1. Does not require modification to electricai or gas service. <br /> 2. Has a totai cost of$500.00 or less;excludine the cost of the fixture or appliance:and <br /> 3. ls 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 Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> . � ,,.,.,..�.'�J��:...,��, .�. _..,�����i'��c�f���.,:3y�`.�a�.��!IY�{.�S.Y.�G���d�h.ti�'.A+fi3:y.�� <br /> ��� <br /> lf above does not appiy;follow guidelines below: <br /> 1. CONTRACT PRICE * is 1.25%of contract price with a(Minimum Fee ot$50.00) <br /> —`(�7� x.0125$ ��`70 �� <br /> (contract price) (minimnm$50.00) <br /> 2. STATE SURCHARGE �.g <br /> cl�f 7� a.000s $ �- <br /> (conVact price) ` <br /> 3. POSTAGE&HANDLING(Only on Mail-In Applications) $ 2.00 <br /> 4. TOTAL PERMIT FEE(Add Lines 1-3 Above) $ �oC.% • 6 7 <br /> ■ * CONTRACT PRICE or JOB COST means the actual or estimated dollar amount charged for the <br /> permitted work including materials, labor,profit,and okher 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 itams must be added to the <br /> estimated cost or coniract price for permit fee purposes. ln 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. <br /> „. . .. .{�':'.,.. '����'.�..s.. .�'�'�_. . . ..'` ' .. �.�:�'�.���'_.�.►,�.a_�}��^� ��; ��`,�..'.: <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 Ciry 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 /> Applicant's Signature: -L r/�� Date: J �/ �� <br /> 3 <br />