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� . ., � 3� <br /> � a �0 <br /> Please check one: New x Addition <br /> JOB SITE 2 I� ��o.t>`����� �l� - <br /> Owner'sName �C�- ��-`T TelephoneNurriber �-�2" `�7l� ll��. <br /> Malirig Address Z!� sk��`Y �-��� ��: . <br /> Spr�inkler Contractor's Name `7'a.�bS��� Telep�one Number qs'z-�7- z�s y <br /> � �`l' 3�3- 33�s' <br /> Contact Person I �u.� w:/�v� <br /> Ma�ing Address F��7 �-F�1�r��T �c s d�,-y . <br /> �VA'I'F'R�I�pLY <br /> Lake�_ Well City <br /> BAC'KFLO�V DEVICE • <br /> • AVB PVB . . <br /> ' Year of <br /> Make odel Manufacture an i <br /> Sprinklers � �tag�� s'cr�� -r�v.�p �1 $� <br /> o �4i�3�2�_)Sao�..�p�r.,��r� z�� 7�-I <br /> - TOTAL � �f� _ <br /> �'YDRAULIC CALCULATIONS Design Data: � <br /> Area of Application: �l S%-/y Sq. Ft. <br /> Coverage per Sprinkler: I 3 _Sq. Ft. <br /> No. of Sprinklers: _ 5 g <br /> Total Water Required: 2 � � �� ps: GPM <br /> �ER�I�IIT FEE CALCULATION <br /> 1, Permit Fee $ 35.00 <br /> 2. State Surcharae $ .50 <br /> 3. LViail-In Fee .- � - � $ 1.50 <br /> 4. TOTAL PER1tiIIT FEE (Add lines 1-3 above) $ <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 siatements made on this application are complete, true and correct. <br /> / <br /> - Applicant �. Date S �/ <br /> ********«******** *********************************************** *****�******** <br /> Approved �`� S Approved with Corrections Denied _ <br /> Reviewed by: ` <br /> �j'��bC f " nr-c.��. Date 7- 5�-c� � <br /> ���� #'D i( �t�5��C_ti C r, �"��1�.0+� n l�t�:Z .. <br />