1278 Town Centre Dr - Suite 190 �
Use BLUE or BLACK Ink
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� For Office Uge �
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�� �f �a �� RECEIVET� ; Permit#:
� � 2��5 j Permit Fee: ���1� i
3830 Pilot Knob Road DEC 21 i i
Eagan MN 55122 I ��-� �������
Phone:(651)675-5675 � Date Received: �
Fax:(651)675-5694 � � Staff: �� �
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2015 FIRE SUPPRESSION SYSTEMS PERMIT APPLICATION
Date: �� �.S Site Address: ��.'�U T�Wa VEKTit.E �R•
Tenant: d"T'���� � /"tC.�'� Suite#:__��• / � �— -
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� �� ' Name: Phone:
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� Address/Gity/Zip:�
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�� Applicant is: Owner _Contractor
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�, .�.�������� Description of work: ��i 0.1J �!►OA�vT RG,wOS���'� �S
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� � Construction Cost: d�•O0 Estimated Completion Date: �E U..�
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a ��� Name: �.4G� License#:
�I � ' ��: Address:���� �� �t: City: gZ•�J `
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�; State:�N Zip: ���� Phone: �/� ��'J�v
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�� _„ Contact: � I 0 Email:
� FIRE PERMIT TYPE WORK TYPE �
, �Sprinkler System(#of heads� _New _Addition �
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� �Fire Pump _Standpipe _Alterations �Remodel
� Other: Other:
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� DESCRIPTION OF WORK: �Commercial _Residential _Educational
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� $60.00 Permit Fee Minimum Contract Value$ •� x.01 �
;
� Surcharge=Contract Value x$0.0005 =$ � �� Permit Fee
� If the project valuation is over$1 million, please call for Surcharge � �
r =$ . � Surcharge
� $100.00 Residential New(includes State Surcharge) _$ /� 9 � �
�� taO• TOTAL FEE �
� 3/4"Displacement Fire Meter-$270.00 =$ Fire Meter �
�� _$ TOTAL FEE
**Requirements:2 complete sets of drawings and specifications,cut sheets on materials and components to be used
I hereby apply for a Fire Suppression System permit and acknowledge that the information is complete and accurate;that the work will be in
conformance with the ordinances and codes of the City of Eagan and with the Minnesota Building/Fire Codes;that I understand this is not a permit,but
only an application for a peRnit,and work is not to start without a permit;that the work will be in accordance with the approved plan in t _ se of work
which requires a review and approval of plans.
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Applicant's Printed Name Ap ca 's gnature
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CQndition�of Issu�nce: : : �, : ; _;
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