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r <br /> Z/ <br /> q � -�} ��2� <br /> � <br /> ��� <br /> Please check one: New V Addition <br /> JOB SITE <br /> Owner's Name ,�d ���,���.� Telephone Number �%7�- ��p �" <br /> Mailing Address f�/O S - « f�-� <br /> Sprinkler Contractor's Name�y� �w� ���r��Telephone Number �/����25'G <br /> Contact Person ;� - ��� <br /> Mailing Address , � c� ��3� / r��� f'� <br /> WATER SUPPLY ' <br /> Lake �_ Well Ciry <br /> BACKFLOW DEVICE <br /> AVB PVB RPZ <br /> Year of <br /> Make Model Manufacture uantit <br /> S rinklers �� <br /> S�^��s �c�� � 3�' <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 $ 35.00 <br /> 2. State Surchar�e. $ .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. TOTAL PERMIT FEE (Add lines 1-3 above) $ <br /> The undersigned hereby applies to the City for issuance of a Sprinkler System Permit, agrees <br /> to do all work in strict accordance with the ordinances of the City and State regulations, and <br /> certifies that all statements made on this application are complete, true and correct. <br /> � , <br /> Applicant Date � �� <br /> �*****�***********************************x�******��x**�*��*�************x�****** <br /> Approved Approved with Conections Denied <br /> � <br /> Reviewed by: . <br /> � Date � � �� <br />