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r04 Fax A1/3y� <br /> 77 <br /> � f C <br /> ❑ New ❑ Addition Remodel ❑ Replace <br /> Site Address: S <br /> Owner: 1 &N6U'ling Address: g+,-l' p, , f • <br /> City: U r I Zip: <br /> Home Phone: q�Z Alternate Phone: <br /> Contractor/App.: i`U r�V1 - YPY(Yk��ontact Person: <br /> Address: �� L� (tiV�� 4- State License#: <br /> City: �OLVJ Zip: 01�lI Expiration Date: <br /> Phone: lD� 7�D �J�(� Alternate Phone: <br /> Commercial—Fire Sprinkler ❑ Residential—Fire Sprinkler <br /> - Fire Systems Permit Fire Systems Permit <br /> *Base Price=Contract Price:$ 56:11 `5.OQ.0125 =$ �O . (� (Minimum$35.00) <br /> *Surcharge=Contract Price:$c5 %1-3.UDg.0005 =$ 2• (Minimum $ .50) <br /> *Mail-In Fee(Only On Mail In Applications) _$ 1.50 <br /> *Total Cost of Permit: _$ -7 4.5 O <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 /> application are complete,trued correct. <br /> 1 U- / <br /> 0 tS <br /> Applican Date <br /> U;7, IN <br /> I✓ � �p <br />