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` � ' <br /> . <br /> Please check one: New Addition <br /> JOB SITE C� <br /> / <br /> Owner's ame ,,�,5 , TelephoneNurriber � <br /> Ma�ing Address - <br /> Sprinkler Contractor's e , TelephoneNumber �L�.��//'�G <br /> Contact Person � <br /> / • /�,�r.t..,.., �� <br /> Mailing Address � � <br /> � ' <br /> �VATER SUPPLY <br /> Lake Well City <br /> BACKFLO`V EVI • <br /> � AVB PVB <br /> � Year of <br /> ake odel �Vlanufacture uanti <br /> Sprinklers <br /> . � TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: � <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: <br /> Total Water Required: Gp� <br /> PERil�1IT FEE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> 2. State Surchar�e $ .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. TOTAL PER.D�IIT FEE (Add lines 1-3 above) $ <br /> The undersi;ned hereby applies to the City for issuance of a Sprinkler System Pernut, agrees to do <br /> all work in strict accordance�vith the ordinances of the City and State regulations, and certifies that <br /> all statements made on this application are complete, true and correct. <br /> - Applicant , Date ���� <br /> ***************************************************#********�** ***************** <br /> Approved M Approved with Corrections Denied <br /> Reviewed by: <br /> Date � '�� � 1� � <br />