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C `i�c <br /> �..,�., �. ';�. , , . �4',���r�r���:..,...... ........���`A���^�LR\,F.i�"�i���J�i�;L ,�,�',,,it ��,�. <br /> �PI a C:heck One_-- � <br /> � New ❑ Addition ❑ Remodel ❑ Replace <br /> r� ���� � � _� x ��������, �E <br /> t�T��.�i�ri �� � � <br /> ��� e,. :.��. _.> �f�, � <br /> Site Address: �o�a�S Cd S�D ���r c.�e <br /> Owner: <br /> Le�eS-f-w� a Mailing Address: �'�Y Za�'� ,�/�N <br /> City: � �0 /�1.0 Zip: ��`3 � � <br /> Home Phone: Alternate Phone: <br /> W� N �k� � ��\��1✓ � L�u���,�y�^'�„� � �`s'. <br /> ➢ <br /> Contractor/App.: � ►/� ��'r Contact Person: '� �� OVS,��/ <br /> / <br /> Address: 30� ).✓or k A �e • State License#: C��S <br /> City: .�, t�evt K � Zip: -��� Expiration Date: � �� <br /> Phone: �/— .SS�'' 3 3 O a Alternate Phone: 6�l— SS g- 3a a � <br /> � .�P�����T v ����'RIl'�T�ER�1'����['��. ? r,��., , ����� �� <br /> ❑ Commercial—Fire Sprinkler �Residential—Fire S rip nkler <br /> Fire Systems Permit Fire Systems Permit <br /> * Base Price=Contract Price: $ I7�, 4���x.0125 =$ Ot o��• D( (Minimum$50.00) <br /> �- <br /> * Surcharge=Contract Price: � � OT x.0005 =$ l• � <br /> * Mail-In Fee(Only On Mail In Applications) _$ 2.00 <br /> *Total Cost of Permit: _$ ��• 9 4� <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 Code,Minnesota State Fire Code and Standards, and certifies that all statements made on this <br /> a lication are complete,true and correct. <br /> .� � y ,o �.� <br /> Applicant Date <br />