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� �o <br /> �J� � � � � '� <br /> Please check one: New_� Addition <br /> , JOB STTE <br /> :' y7�2 ,�',�,��.���<,r� ��� <br /> . <br /> Owner's Name ��''�7 �nG�,G G N1� TelephoneNumber �/�.- ��,���GGS' <br /> Mailing Address_� 4 � rC� a i✓� S� �i��S; �'.x.% �;����/ <br /> Sprinkler Contractor's Name �u l s� Li/�t,�� TelephoneNumber jv/�- k�7 �GC�' <br /> Contact Person �Uly,v �7(��`��� <br /> Mailing Address ��U� N ��t/•� �J �-y��� ,�,�, �; S ."l/- �� . <br /> � — <br /> `VATER SUPPLY <br /> Lake Well City x <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers <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: Gp� <br /> PERMIT FEE CALCULATION <br /> 1. Pernut Fee $ 35.00 <br /> 2. State Surchar�e $ .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. TOTAL PERNIIT FEE (Add lines 1-3 above) $ 3 5. 5v <br /> The undersi?ned 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 application are complete, true and correct. <br /> � <br /> n ��� �� n� <br /> Applicant �i� Date y <br /> *******************************************************�************�************ <br /> Approved Approved with Corrections Denied <br /> Reviewed by: / <br /> ��i�C�/ Date ��` �� <br />