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� � ' ��o�� <br /> Please check one: New �( Addition _ <br /> aoBs1� U .� u� ��i�r� r��� ��; �� - :�,�: �e�� � = <br /> Owner's \Tame i � �C +���� Telephone Number <br /> Mailing Address �a��" ��tr 1� �'�ic t�r, Uu '�,;��� S S 3�=� i <br /> Sprinkler Contractor's Name �K.v}'��,��/ ��.,,:� ����'�phone Number '�7L �r�� <br /> ,, <br /> Contact Person �-���1�=• � � �.cli ��«.� <br /> Mailing Address �� �� �'���. �� ��f�� ��L,�Gj �t.{� <br /> WATER SUPPLY <br /> Lake Well �'� City <br /> BACKFLOW DEVICE � <br /> AVB PVB �_ <br /> Year of <br /> Make Model Manufacture uanti <br /> S�rinklers Ir�� :u �,=t '%'�'� �f � �,,� <br /> � , � � ��� � . ��� z.�.. <br /> . <br /> TOTAL�� <br /> HYDRALTLIC CALCULATION Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. . <br /> No. of Sprinklers: <br /> Total Water Required: GPM <br /> PERIVIIT FEE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> 2. State Surcharge. $ .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 to <br /> do all work in strict accordance with the ordinances of the City and State regulations, and certifies <br /> that all state ts made on this application are complete, true and correct. <br /> . ` � . : _ <br /> Applicant Date ? 7 <br /> ��F�kX�X�M��3�%k�k�cx�(ea;cx�c�c�e�;c�k�k������k�k�k�k3���c�c$c�e�$eic$ca;cxcxa;ea;e�(ca,c$cs;c�k��e�cs;exhcxxie$exs;ciea;c�c�;e3e�eiea;e�!c3,c$ci,c$c <br /> Approved Approved with Corrections Denied <br /> Reviewed by: -� <br /> Date � �� � � <br />