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I <br /> Please check one: New � Addition <br /> aos srrE 3�a� si��e�,,,� d r' , �J�..�, Zw-��- � <br /> Owner's Name .� �. �(Yl�k '�6�4v e� Telephone Number �i S Z`�7 I o75� <br /> Mailing Address_�' �4�Gt���S���,1� re d� �a..�,,Za--�� � . <br /> Sprinkler Contractor's Name_ � �� TelephoneNumber 9SZ�/7a�s <br /> Contact Person yVl a r� �e r,�e l <br /> Ma�ing Address `.� S(>�� �� . <br /> `VATER SUPPLY <br /> Lake Well City �- <br /> BACKFLOW DEVICE <br /> . AVB �-PVB <br /> � Year of <br /> ake odel Manufacture uanti <br /> Sprinklers }��v�,-�e�r 1 `Z� O3 l� <br /> - � TOTAL <br /> f� <br /> HYDRAIJLIC CALCULATTONS Design Data: � <br /> Area of Application: I 0, o0b Sq. Ft. <br /> Coverage per Sprinkler: _ 7 dU Sq. Ft. <br /> No. of Sprinklers: � <br /> Total Water Required: �Z Gp� <br /> PERNIIT FEE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> 2. State Surcharge $_ .50 <br /> 3. Mail-In Fee � $ 1.50 <br /> 4. TOTAL PERNIIT FEE (Add lines 1-3 above) $ <br /> The undersigned hereby applies to the City for issuance of a Sprinkler System Pernrit, a�rees 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 /> Applicant Date <br /> ********************************************************************************* <br /> Approved Approved with Corrections Denied <br /> Reviewed by: <br /> Date <br />