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1a <br /> Please check one: New Addition <br /> JOB SITE <br /> Owner's Name t c-,t r� LU Telephone Number <br /> Mailing Address c�- 0 <br /> i <br /> Sprinkler Contractor's Name X,n <br /> �i-pNumber y��2 <br /> Contact Perscn <br /> Mailing Address S CU o ! <br /> WATER SUPPLY <br /> Lake Well City j <br /> BACKFLOW DEVICE I <br /> AVB PVB _ <br /> Year of <br /> Make Model Manufacture Quantijy <br /> Sprinklers ILIV /O <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: /cR,) Sq. Ft. <br /> No. of Sprinklers: -�1n <br /> Total Water Required: 4L qr GPM <br /> PERTMIT FEE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> 2. State Surcharge. $ .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 to <br /> do all work in strict accordance with the ord' nces of the City and State regulations, and certifies <br /> that all statements made on thi applicatio are complete, true and correct. <br /> Applicant Date <br /> k3�ie�er'e�ekk�k#kkk�kas$ckk�kkkkkk�kkkkXk!ekk�c�xcic3eae�eacsesc�cyck�kk3 ;caeac;c$e;cue$ex3,e3,cx;c!c3ek�F���Xk <br /> Approved Approved with Corrections Denied <br /> Reviewed b <br /> ` Date <br />