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�!"�,G,�_'� <br /> Please check one: New / Addition <br /> JOB SITE �Q6 �/_,� CJ..�'�A K �(/9 c� � �fZ - <br /> Owner's Name - s ' - Telephone Number <br /> Mailing Address �� �li �' <br /> Sprinkler Contractor's Name_�_�/�= C'-- Telephone Number � Z � <br /> Contact Person � J j�� <br /> Mailing Address �� ���_�'�� (��i 1'�/9 OV �1,�l� Gs�. �Q" <br /> WATER SUPPLY <br /> Lake Well City � <br /> BACKF'LOW DEVICE <br /> AVB PVB r/ RPZ <br /> Year of <br /> Make Model Manufacture uanti <br /> S rinklers <br /> �ro�raL 9 <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: f — Sq. Ft. <br /> No. of Sprinklers: <br /> Total Water Required: /? � � GPM <br /> pERMIT FEE CALCULATION $ 35.00 <br /> 1. Permit Fee $ .50 <br /> 2. State Surcharge. <br /> 3. Mail-In Fee � —� <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 this application are complete, true and correct. <br /> Applicant - C- �-- � �L� � Date � l� <br /> *�***�*�****************************************�***x��*******�****�******�**** <br /> Approved Approved with Conections Denied <br /> Reviewed by <br /> ��_, - Date lj � <br />