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Please check one: New _� Addition <br /> JOB SITE <br /> Owner's Name �.l Telephone Number <br /> Mailing Address'��S"rq�►-� <br /> Sprinkler Contractor's Name Telephone Number 40 q•.. .{�.S^` <br /> Contact Person <br /> Mailing Address ��- <br /> WATER SUPPLY <br /> Lake Well City <br /> BACKFLOW DEVICE <br /> AVB PVB 1/ <br /> Year of <br /> Make Model Manufacture Quantity <br /> ,Sprinklers �.�r�cr /'�C � /�1 V <br /> TOTAL 3r <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: GPM <br /> PERMIT 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 ordinances of the City and State regulations, and certifies <br /> that all statements made on this application are complete, true and correct. <br /> Applicant Date e <br /> Approved Approved with Corrections Denied <br /> Reviewed b <br /> Date <br />