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• <br /> /4/o//9 <br /> New ❑ Addition 4�%/ Remodel — Replace <br /> se, srE .. <br /> IMO <br /> Site Address: rl03 C S-OJ " l-e Poi • <br /> Owner: (DiMf Q h(' 01). Mailing Address: Po f'/ Lica <br /> City: OIOnC Zip: <br /> Home Phone: (.0 I�- - 11 Log - PGternate Phone: <br /> Contractor/App.: t At - ,i. S • Contact Person: I I - at <br /> Address: I lAt I. ! State License#: C -60S— <br /> City: <br /> 6 S— <br /> City: WILLI_„St_ Zip: 5J/t'/ Expiration Date: <br /> Phone: Alternate Phone: <br /> tea:: 'firfir <br /> ommercial–Fire Sprinkler ❑ Residential–Fire Sprinkler <br /> Fire Systems Permit Fire Systems Permit <br /> *Base Price=Contract Price: S—/ 101) . ^ x.0125 =$( 76 (Minimum $35.00) <br /> *Surcharge=Contract Price:$CJS IOU x.0005 =$ I , (Minimum $ .50) <br /> *Mail-In Fee(Only On Mail In Applications) =$ 1.50 <br /> *Total Cost of Permit: =$ 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 com.lete,true and correct. <br /> ►1 ► 1.. . _l � <br /> ► 1 `1- l5 -0( <br /> � <br /> Ap.icant Date <br />