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� . Please check one: New� Addition <br /> JOB srrE 3 l �c.c ss � �� . <br /> Owner's Name J C��� ��1�'''��J e II Telephone Number �S—�— �f 76 O�/� <br /> Mailing Address 3 9S J�t..�Se?c <n <br /> Sprinkler Contractor's Name , e i�� TelephoneNumber 7� ,3—��y�?2 <br /> Contact Person l� � <br /> Mailing Address _d v 3 � � /�'1/1. S�_j 7 <br /> WATER SUPPLY <br /> Lake Well� City <br /> BACKFLOW DEVICE <br /> � AVB PVB� <br /> Year of <br /> Make Model Manufacture uantit <br /> Sprinklers -�c — Cy <br /> 6 d � <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: � Sq. Ft. <br /> Coverage per Sprinkler: � s' Sq. Ft. <br /> No. of'�r.i.nklers: �o� <br /> Total Water Required: �p GPM <br /> PERMIT FEE 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) $ �S.S v <br /> The undersigned hereby applies to the City for issuance of a Sprinkler System Permit, agrees to do <br /> a11 work in strict accordance with the ordinances of the City and State regulations, and certifies that <br /> all statements made on this ap lication ar omplete, true and correct. <br /> Applicant � Date � �( ��-- <br /> ***�******************** ****************************************************** <br /> Appro�ed �^� Approved with Conections Denied <br /> Reviewed by:�� Date �'�'6" ��— <br />