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<br /> <br />Building Codes & Standards Division <br />408 Motro'Square Building <br />7th and Robert Streets <br />St. Paul, MN 55101 <br />(612) 296-4639 <br /> <br />Exhibi t B <br /> <br />If you are administering the Build- <br />ing Code for other municipalities, <br />please list them on the reverse side. <br /> <br />Department ot , <br />Administration .' <br /> <br />BUILDING PERMIT SURCHARGE REPORT <br /> <br />Quarter Ending Year <br />(POPULATION 20,000 OR LESS) <br /> <br />Reporting Unit Cou nty I Telephone No.linclude Area Code) <br />Municipality <br />Addre'ss City, State, Zip <br />Name of Building Official 0.0. Cur lifit:nllon Nurnhur I Tlllophone No. (Include Aroo Codo) <br /> <br />PART "A" PERMITS BASED ON FIXED FEE: <br /> <br />The surcharge computation is based on the permit fee. <br />Surcharge equals .0005 of each permit fee, or 50~, whichever is <br />greater. <br /> <br /> (Fee Less Than $1000) (Fee More Than $1000) <br />Type of Permit: Number of Number of Total <br />Permits Total Permits Fee <br />Plumbing Times 50~ Times .0005 <br />Electrical Times 50t Times .0005 <br />Mechanical Times 50~ Times .0005 <br />Other Times 50~ Times .0005 <br /> Total $ Total $ <br /> Total part "A" $ <br /> <br /> <br />Where Valuation of <br />Construction Per <br />Permit Issued Is: <br />$1,000,000 or Less <br /> <br />$1,000,000 to $2,000,000 <br /> <br />$2,000,000 to $3,000,000 <br /> <br />$3,000,000 to $4,000,000 <br /> <br />$4,000,000 to $5,000,000 <br /> <br />$5,000,000 and over <br /> <br />The surcharge computation is based on the valuation of construction. <br />Valuation shall be based on Table established by the Division. <br /> <br />PART "B" PERMITS BASED ON VALUATION: <br /> <br />Number of <br />Perm its <br /> <br /> <br />Total Valuation <br /> <br /> <br />Total <br /> <br />$ <br /> <br />M = 1,000,000 <br />N/A= Not Applicable <br /> <br />(Shaded Area Division Use Only) <br /> <br />TOTAL PART "B" <br /> <br />$ <br /> <br />TOTAL PART "A" AND "B" SURCHARGE $ <br />LESS 40/0 RETENTION <br />TOTAL SURCHARGE REMITTED <br />(CHECKS MADE PAYABLE TO "STATE TREASURER") <br /> <br />I hereby certify the information contained herein to be true and correct. <br /> <br />Signed <br /> <br />Title <br /> <br />Date <br /> <br />Original must be fully completed and sent together with surcharge remittance, to the State Building Inspector, 408 Metro <br />Square Building, Seventh and Robert Streets, St. Paul, Minnesota, 55101 by the 15th of the month following the reporting <br />month. Duplicate may be retained for your files. Checks are to be made payable to the State Treasurer. <br /> <br />BC-00012-Q2 <br />