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. <br /> Please check one: New Addition . <br /> JOB SITE �,�,u i�.c(� �LL. �.o�-�- ��.,v� <br /> Owner's Name Telephone Number��z-4-�_�g-��.--- <br /> Mailing Address 1 C�c� S�z,,�s..6 �a.-�L.� �Z�„�t <br /> Sprinkler Contractor's Name�o sc��s l�►�.x.�w��,-�Telephone Number 4vz-9 z�--�6 S 3 <br /> Contact Person 1��� �,�c�,�; <br /> Mailing Address <br /> WATER PLY� <br /> Lake Well City <br /> $ACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture Quantity <br /> S�rinklers � Tz.C•> �c� S�r�� T�C�tz.�-� G,- <br /> �" ►��5 <br /> TOTAL <br /> HYDRAULIC 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 /> PERMIT FEE CALCULATION <br /> 1. Permit Fee $ _ 35.00 <br /> 2. State Surchar�e. $ .50 <br /> 3. �Vlail-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 made on this application are complete, true and correct. <br /> Applicant ���� Date <br /> x��x��x��* ��x�� ��a�*����x�*a����������a��x�*�a�x�������k*�����*�a���*���*�a���x��k�k�*�x�x�x� <br /> Approved Approved with Corrections Denied <br /> Reviewed by• � <br /> �' . <br /> �` Date � <br />