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<br />~ <br /> <br />Oulldlno Codoa & Standarda Division <br />408 MolrOSquaro Dull dIng <br />7th and Robart Stroots <br />St. Paul. MN 55101 <br />(612)296-4639 <br /> <br />Exhibi t c <br /> <br />II you ar, admlnlaterlng the Build- <br />Ing Cod. lor other munlclpallU... <br />plllse 1111 Ih,m on Ih, reverse side. <br /> <br /> <br />BUilDING PERMIT SURCHARGE REPORT <br /> <br />~partment or <br />.dministrauon . <br /> <br />Quarter Ending Vear <br />(POPULATION 20,000 OR LESS) <br /> <br />Reportin~ Unil County I T.I.phon. No. tlnclud. AI,. Code) <br />Municipa ity <br />Acldr"l Clty, Sill.. ZIp <br />Name 01 Oullding Olllelal D.O. Cu,lilk:atloll NUII\l1Al I Tolophon. No. (lnclud. AlaI COdDI <br /> <br />Type of Permit: Number of Numb., 01 Tot.. <br />P,rmlts Total Permlta F,. <br />Plumbing Times 50~ Times .0005 <br />Electrical Times 50_ Times .0005 <br />Mechanical Times 50~ TImes .0005 <br />Other Times 50_ TImes .0005 <br /> Total $ Total $ <br /> Total part "A" $ <br /> <br /> <br />PART "A" PERMITS BASED ON FIXED FEE: <br /> <br />Wher, Valuation 0' <br />Construction Per <br />Permit Issued Is: <br />$1.000.000 or Less <br /> <br />$1,000,000 to $2,000,000 <br /> <br />S2.000,000 to $3.000,000 <br /> <br />$3.000.000 to $4.000,000 <br /> <br />$4.000.000 to $5.000.000 <br /> <br />S5.000.000 and over <br /> <br /> <br />The surcharge computation Ii 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 />M - , ,000,000 <br />N/A - Not Applicable <br /> <br />(Shaded Ar.. Division USI Only) <br /> <br />TOTAL PART "8" <br /> <br />s <br /> <br />TOTAL PART "A" AND "B" SURCHARGE $ <br />LESS 4% RETENTION <br />TOTAL SURCHARGE REMITTED <br />lCHECKS MACE PAVABl.& TO "STATE TREASURER") <br /> <br />I hereby certify the Information contained herein to be true and correct. <br />Signed Title <br /> <br />Dato <br /> <br />Original must be fully completed and sent togother with surchargo remittance, to the State Building Inspector, 408 Metro <br />Square Building. Soventh and Robert Streets, St. Paul, Minnosota. 55101 by tho 15th 0' tho month following tho roporting <br />month. Duplicato may bo retained for your files. Chocks are to be made payable to the State Treasurer. <br /> <br />IC.COOU.oZ <br />