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1 <br /> Please check one: New ;/ Addition <br /> JOB SITE rp A/ X �e AIN Laf.S T n!1(4 t J A �'� <br /> Owner's Name ,�A.)/_ ,6e,yAl v_� Telephone Number 7,-3 7� <br /> XJ <br /> Mailing Address SIS T N k�WA X /�'�aJ. S S-3�( <br /> Sprinkler Contractor's Name r Telephone Number ,S� f� <br /> Contact Person <br /> Mailing Address _ 0-3 5Z- /✓d V <br /> WATER SUPPLY <br /> Lake Well City <br /> BACKFLOW DEVICE / <br /> AVB PVB RPZ A i/ <br /> Year of <br /> Make Model Manufacture Ouanti <br /> Sprinklers s a 14-000 f 9, Q X33 <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: 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 <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 /> Applicant Date v2 0'A <br /> Approved Approved with Corrections Denied <br /> Reviewed by: <br /> Date <br />