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} <br /> Please check one: New X Addition <br /> JOB SITE �}�5 TOitlllf�w/9 ,L�t„ <br /> Owner's Name 0&1--r f klmssc f?_ Telephone Number <br /> Mailing Address YC _j QWJVA-w A Ro*yg <br /> Sprinkler Contractor's Name A dWAL . c. Telephone Number -fyL-LIS o <br /> Contact Person {A,.y. *je <br /> Mailing AddressL,,�(, t C,r�, u)j!!=j �i�iMWE 4 <br /> WATER SUPPLY <br /> Lake Well City <br /> BACKFLOW DEVICE <br /> AVB PVB X RPZ <br /> Year of <br /> Make Model Manufacture Ouantjjy <br /> SDrinklers 6P /f 9G• lin. <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: Z6 GPM <br /> PERMIT FEE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> 2. State Surcharize. $ .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 /> ApplicantDateRL <br /> Approved Approved with Corrections Denied <br /> Reviewed by: <br /> Date <br />