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:• .AUTOMATIC FIRE`SPRTNKLER'PERNIITS <br /> Pleaseh. lieckOne �.:'.p' <br /> New ❑ Addition ❑ Remodel ❑ Replace <br /> Doti bite Ownx,Informahgn <br /> Site Address: Z o G o W iS51 w A�( Z NMN t3 L v O- <br /> Owner: Mailing Address: <br /> City: Zip: <br /> Home Phone: Alternate Phone: <br /> 7,ContraFfor'/k�;gpltc'�titrTii'formatton`�' ���• ° ; �. <br /> Contractor/App.: n R-� ff oVi-; cmo w Contact Person: 7v 4" Z <br /> Address: top G e k &9 State License#: d o l <br /> City: W pu rc�.zL Y Zip: SS 3g 0 Expiration Date: (o -.3 Q - �o <br /> Phone: 9�3•- S'�- 14 �c, 3 Alternate Phone: &53s- <br /> Commercial <br /> 53rCommercial—Fire Sprinkler ❑ Residential—Fire Sprinkler <br /> Fire Systems Permit Fire Systems Permit <br /> pa <br /> *Base Price=Contract Price:$ 9-- 0 0 x.0125 =S //Z5 '' (Minimum$35.00) <br /> *Surcharge=Contract Price:$ q. O 0 o o x.0005 =$ Y (Minimum $ .50) <br /> *Mail-In Fee(Only On Mail In Applications) =$ 1.50 <br /> 0 <br /> *Total Cost of Permit: =$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 Code,Minnesota State Fire Code and Standards,and certifies that all statements made on this <br /> application are complete,true and correct. <br /> 3 -L7- oma <br /> Appli wap Nlrua�scti, kyIN ��/1�1Ct�Date <br /> "96t <br /> 0,111" <br /> & @ <br /> m4 ffi+ <br />