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t � ' <br /> Please check one: New Addition <br /> JOB SITE o� v� � <br /> Owner's Name Telephone Number 7/-- � D� <br /> Mailing Address p`���� ��q �,c�[9d� � ��nC� ��-3 9� <br /> Sprinkler Contractor's Name�C�t �tWli �Pi�n�f1^STelephone Number ��6-"���� <br /> Contact Person � e r�'�Z <br /> Mailing Address 3� D i � r Jd � L�-�►Q �/lJ Jr �� <br /> Lake Well City <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> Ma._ke Model Manufacture Ouanti <br /> Snrinklers <br /> Z'OrTAL <br /> HYDRAiTLIC C.�I� LTI�ATIONS Design Data: <br /> Area mf Application: Sq. Ft. <br /> Cove�age per Sprinkler: Sq. Ft. <br /> No. df Sprinklers: <br /> Total Water Required: GPM <br /> PERMIT FEE CAY.CULATION <br /> 1. Pemut Fee $ 35.00 <br /> 2. State Surchalrge. $ .50 <br /> 3. N1ai1-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 to <br /> do all work in strict accordance with the ordinances of the City and State regulations, and certifies <br /> that all statements #nade on this application are complete, true and correct. <br /> Applicant Date � � � <br /> **********�**�* *******x�x�x�***�****x�*****�**************�**�******x�**��******** <br /> Approved Approved with Corrections Denied <br /> Reviewed by: <br /> Date /��J LS <br />