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'- AUT MATIC.FIRE SPRINKLER PERMITS <br /> Please Check One <br /> ❑ New Addition ❑ Remodel ❑ Replace <br /> Backflow Device: n AVB n PVB <br /> Job Site°l Owner Info iation <br /> Site Address: } N C 0La CRAI S-ru X SA1-I t o b <br /> Owner: S 2.� Z7 Mailing Address: <br /> City: Lo)QC,, Loye_t; Zip: SS-3S . <br /> Home Phone: Alternate Phone: <br /> Contractor l Applicant Information: <br /> tee....... <br /> f3 'a-rt4 <br /> Contractor/A pp•: '' - Contact Person: Ra - v G Ct7K <br /> Address: 80-5 S Sreta rt p 12-1V6 State License#: C.�r I Z'(P <br /> City: SA- • J ptA Zip: 5(0374- Expiration Date: jc.„of30, 2.0 t$ <br /> Phone: CPS 24)J 3edo 3 r° 00 Alternate Phone: <br /> TYPES tli`:FIRE SPIINICLER PERMITS <br /> tigr Commercial-Fire Sprinkler ❑ Residential-Fire Sprinkler <br /> Fire Systems Permit I 41(2.51x <br /> Fire Systems Permit <br /> *Base Price=Contract Price: $VA'S t(2.S 1Q x.0125 =$ 2,o48.q <br /> t( (Minimum$50.00) <br /> *Surcharge=Contract Price:$t(O , `(2.Six.0005 =$ <br /> *Mail-In Fee(Only On Mail in Applications) =$ 2.00 <br /> *Total Cost of Permit: =$ 21 t 32 . <br /> The undersigned herby applies to the City for issuance of a Sprinkler Systems Permit. Applicant agrees <br /> that all systems shall be designed,installed and maintained to N.F.P.A.-13,N.F.P.A.-25,Minnesota State <br /> Building C Minn ,ota tate Fire C e and Standards,and certifies that all statements made on this <br /> applicat . co .'ete rue and co t. <br /> Z S 2o/$ <br /> Applicant Date <br />