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i <br /> � ��� ���� �` <br /> ' Please check one: New �Addition � _ <br /> � � <br /> JOB SITE 5 �.� ��r,�� �, ,�/ (Z�'-. _ <br /> � _ <br /> Owner's Name����,•.� ���(/y���� Telephone Number�f LO�1---�j��L� <br /> Mailina Address S�}c� � �}5 ��`cv� <br /> Sprinkler Contractor's Name��u,.�� ���D�� / �G . Telephone Number ��-����' <br /> Contact Person ��i�f 2�S <br /> MailingAddress 1�- (� • �c� /� L �� C ��`�� 1�i� S`-5'� S`�� <br /> WAT'ER SUPPLY . <br /> Lake Well � City <br /> BACKFLOW DEVICE / � <br /> AVB PVB i/ <br /> Year of - <br /> ake de a u actu uanti -- --� <br /> er � _ c�-c� �,r ,. ��� X c�,��,.,:_ �-� �Z._--1 <br /> � %, � - <br /> f_�� c C';��� � ,„�-,�.�c <br /> � " L > � �i <br /> ��`' <br /> . . TOTAL G <br /> �3YDRAITLIC CALCITLATION Design Data: <br /> Area of Application: b�, ,���;-(� Sq. Ft. <br /> Coverage per Sprinkler: (��;n, Sq. Ft. �,_ <br /> No. of Sprinklers: <br /> Total Water Required: _ ,,; GPM <br /> PERtvIIT FEE CALCLTi�ATION <br /> 1. Pernut Fee <br /> $ _ 35.00 <br /> 2. �tate Surchar�e. $ .50 <br /> 3. Mail-In Fee $ ��,g. <br /> 4. TOTAL PERMIT FEE (Add lines 1-3 above) $ �3�: ��: <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 rewlations, and certifies <br /> that all statements made on this application aze complete, true and correct. <br /> / - <br /> Applicant _ /�l� � �� <br /> �� »-�-�� Date <br /> �k-k�k�����k�k�k��.k�=t������k��k�k�k�k���k����k�k���k�k��k��X�k�#�k%�k�X���=k.k�kXx�k�k3,c:!c�r;e�;ea;cx3,c�;cxe�k�kX�!c���c�c <br /> Approved Approved with Corrections Denied <br /> ^ ; <br /> Reviewed by: � - ;; . <br /> % � . -- / <br /> _-_., <br /> " �'1y'G"--` Date `'" -✓ d <br />