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` ' ,�v3 <br /> � �� <br /> � �� <br /> Please check one: New� Addition �� <br /> JOB STTE_�,`� 7 f �'j�- � �.�E�� ��— � l� m�l� <br /> � <br /> Owner's N�e � �J � S 'd 'R r hone Number <br /> Mailing A.c�dress ` <br /> Sprinkler Contractor's N�me� �/UI l�- �l� TelephoneNumber �{�(o— (7 z� <br /> ContaCt Person � (J' �� <br /> Mailing Address �3 7 �� �`� 1 � � � l� �l � (� G� �r• � G o �!�� S 5 3 8' � .. <br /> WATER SUPPLY <br /> Lake Well_� City <br /> BACKFLOW DEVICE <br /> . AVB PVB _� <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers _ 1 f � � -�G T� � Q' ,�'� <br /> S'/_' ,�L� R /�� � <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: <br /> Total Water Required: GPM <br /> PERMIT FEE CALCULATION <br /> 1. Permit Fee $ 3 5.00 <br /> 2. State Surchar� $ .50 <br /> 3. 1,1�ai1-In Fee $ 1.50 <br /> 4. TOTAL PERMIT�EE (Add lines 1-3 above) $ <br /> The undersigned hereby applies to the City for issuance of a Sprinkler System Permit, agrees to do <br /> all work in strict accordance with the ordinances of the City and State regulations, and certifies that <br /> all statements made on this a^�plication are complete, true and correct. <br /> � Applicant Date� � 9 <br /> ************************�******************************************************** <br /> Approved Approve wit Conections Denied <br /> Reviewed by: Date ��'l�7 � <br />