Permits - Permit# 05-10P - 2425 Black Lake Road - 1/1/2005FROM CITY OF SPRING PARK (THU)12 30 2004 15:22/ST.15:21/NO.5011475363 P 2
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CY'Y'Y OF SPRU4G PARK .
4349 WARREN AVENUE
SPRING PA>1M MB4NESOTA MW
Uqq3 942An-er1
APPLICATION FOR PLUMBING PIERMrf
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FROM CITY OF SPRING PARK (THUM 30 2004 15 : 22/ST. 15 : 21 /NO. 5011475363 P 3
Plumbing Pemxit ApplioWan
asaMnKfALCULAMM
2002 Slate statute . Yee, Tbb Section ApOlee
'Abe repbeoemest of a NaldcoliaL tbed =sees A tbl dtbe [alloe i.g
1) to deedical ar Sus eeivim
2) gu a of OD or lees ead AU the east of the ra=m ar ate: and
3) la Improved. *details* car 1be he®eowaer ar coe�taactor.
Slip newt seedon. Coat of t
state SM%b=V s
Mae to Fee s
if above does not apply, fanaw 90141CUM below:
1. 1.25% Of :DokmdJWM* idmil C s - O
:.Q12s
Coatraet Price
2. •w Add 09 St>me Code DWW1oa
Surcharge to each purdt s .i0M $
Coahact Price
Or s.SO, whstbevu k g[eater
s
3. >e (Omly ,ppheat6ods) . 00
4. TOTAL PBli W FM (Add enes 1-3 above) s
* COTITRACI' PRiCIE OR .JOB COST means do ac&ml oredimabd dollar amount ehuged for the
Pew wortbKkdft aaftrhA tabor, pro f, dad other R<ed cock- R is the s mout to be eked
to the ew"mr for the work done Iraq materiak R labor, oringbRaSonare Imbed by
the awaer, teaaol or my atber putt' tote r�easomable a value of loch *tens cease be added a the
estimated cat or contrast price for the permtt fee par�poees- Inthe event liens Isa &spate op the
amount of the jab cost, the City m" reWd 0e of a ftud eW d00 setwd tootract.
* * The STATE SURCHARGE IS AN of the couraet price o"er S1.9^M or SA vhkhevW
is Greater. For v doad." over S1,dt0q M can the pepvta t of IoPedood Servkn for the prke-
?be anded applsee tr We C,,y far a of a P*rEdk 1° do all wos is strict
aeearda—Cc will* the of the Chy sad do r of the State of h0MW*ssla6 and cwdnn tbat all suftsam" spade fire �°° awe sad correct.
ApplicoWs Signatpre