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t-\ca r 3 Z iTh <br /> :.c 4 6 I g s,3. x. 7.v a-.:Y''e 's3 Y F <br /> � � 5 <br /> ❑ New VI, Addition T Remodel ❑ Replace \ (� <br /> Backflo,,,Device: _ PVB <br /> AVB --- � <br /> Job~Site/Owner Information ;< �s � -- <br /> Site Address: - � 1 - <br /> C� <br /> Owner: Z c__ Mailing Address: <br /> City: Zip: <br /> Home Phone: Alternate Phone: <br /> :404:00100.041,041-110040u ,. <br /> Contractori App.: 01-6E1--:-% NJ `Contac Person: \4 .VI 1.3" VI/St •;J <br /> Address: .3'Z-.1 \-3 L..�,\I 4 ��� State License#: 4'6 <br /> City: i _ 4. Zip: 1 Expiration Date: 7f) 1ff) <br /> 1 ` -ih <br /> Phone: �, 2-'�31—"31 ) 1 Alternate Phone: �c �-� Z�0 4 d <br /> `yl Commercial-Fire Sprinkler ❑ Residential-Fire Sprinkler <br /> Fire Systems Permit Fire Systems Permit <br /> *Base Price=Contract Price:$ .1�4 �x.0125 =$ (Minii�►i�ni$50 00) <br /> * Surcharge=Contract Price: $ x.0005 =$ <br /> --)5 <br /> * Mail-In Fee(Only On Mail In Applications) =$ 2.00 <br /> -g <br /> Q � <br /> -1* Total Cost of Permit: =$ -1 - <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 mplete,true and correct. <br /> " -' __.ia10 -- ► -s— - )--\ <br /> Applicant Da*-: <br />