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f � <br /> Please check one: New � Addition � <br /> JOB SITE Q U <br /> Owner's Name _��` Telephone Number <br /> Mailing Address <br /> Sprinkler Contractor's Name��1 j �Q'l7 0 ��Telephone Number ,S 7� Z�� <br /> Contact Person <br /> Mailing Address ��(>� �Q �¢�' f��2 � �Ti�S �� <br /> WATER SUPPLY ' <br /> Lake Well � Ciry <br /> � - <br /> BACKF'LOW DEVICE <br /> AVB PVB � RPZ <br /> Year of <br /> Make Model Manufacture Quantitv <br /> Sprinklers f-��ni-r-�a P 6 P /�1�l G o-f- <br /> TOZ'AL <br /> IiYDRAiTLIC CALCiTLATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: �D 't" <br /> Total Water Required: � R� GPM <br /> PERMIT r'EE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> 2. State Surchar�e. $ .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 <br /> to do all work in strict accordance with the ordinances of the City and State regulations, and <br />� certifies that all statements made on thi pplication are complete, true and conect. <br /> _� q- y_�� <br /> Applicant Date <br /> ***�***���* *******************x�*****��****�***���*****�*x��***********�****** <br /> Approved Approved with Corrections Denied <br /> Reviewe y• <br /> Date � � <br />