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• r I �� / �� <br /> �1 i{� <br /> . � <br /> Please check one: New � Addition � <br /> JOB SIT'E � 3>S _s /�'o�U�,��� �J,�_ <br /> Owner's Name S I�i�C.' ���,�,�/STz�� Telephone Number �{�S -2/�� J <br /> ' ? �` � S /1:�G' c ���o r; ��, <br /> Mailing Address __ ,; � , �� � �� <br /> Sprinkler Contractor's Name (_7L�/�(/�-'�` � Telephone Number <br /> Contact Person <br /> Mailing Address <br /> WATER SUPPLY <br /> Lake Well �� City <br /> �ACKFLOW DEVICE <br /> AVB PVB � <br /> Year of <br /> Make Model Manufacture Ouantitv <br /> , - <br /> �prinklers `T�,� '�` ," �� ,�,�;,� �;�' <br /> TOTAL � <br /> HYDRALTLIC CALCITLATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. . <br /> No. of Sprinklers: <br /> Total Water Required: �7 GPM/��^����� <br /> /� � � G. LrvC"S <br /> PERMIT FEE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> 2. State Surcharge. $ .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. TOTAL PERMIT F'EE (Add lines 1-3 above) $ <br /> The undersigned hereby applies to the City for issuance of a Sprinkler System Permit, agrees to <br /> do all work in strict accordance with the ordinances of the City and State regulations, and certifies <br /> that all statements made on this application are complete, true and correct. <br /> , <br /> , <br /> � /� / <br /> � , <br /> v=r '���.. /`,^'� C�����S� �i:, � <br /> Applicant Date ! � <br /> , <br /> x����������������x����k��������x*:����x����k**��kx���xX�����k���k��x����k������*a��k��*���k� <br /> Approved Approved with Corrections Denied <br /> Reviewed by: <br /> ' � ^ - Date ����'-�%' / <br />