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i <br /> Please check one: New Addition <br /> JOB SITE 5/S 7,A)/<A a)A <br /> Owner's Name �1 r.A A - �r A)J Jt� Telephone Number `3 S �3 <br /> Mailing Address --)A A� �— <br /> Sprinkler Contractor's Name,i;'6 Com- ,�,o/r Telephone Number ,S`� O b <br /> Contact Person / A all <br /> Mailing Address /v - <br /> WATER SUPPLY <br /> Lake Well City <br /> BACKFLOW DEVICE <br /> AVB PVB RPZ <br /> Year of <br /> Make Model Manufacture Quantity <br /> S rinklers <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: Sq. Ft. <br /> Area of Application: <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: GPM <br /> Total Water Required: <br /> PERMIT FEE CALCULATION $ 35.00 <br /> 1. Permit Fee $ 50-- <br /> 2. State Surcharge. $ 1.50 <br /> 3. MailIn 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 /> Date 116 <br /> Applicant <br /> Approved Approved with Corrections Denied <br /> Reviewed <br /> Date <br />