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Please check one: Newy Addition <br /> JOB STTE c(, !`T C,4 (.S �it kt,,- //0 tL �-- <br /> Owner's Name_ /'�, s C,,r T CA r(s 0 Telephone Number A),A <br /> Mailing Address <br /> Sprinkler Contractor's Name ZkP SP r r'A l<('c c Telephone Number <br /> Contact Person Z1,eA �,�— Go p fn <br /> Mailing Address 10 -7V Y,,\/d <br /> WATER SUPPLY <br /> Lake'_ Well City <br /> BACKFLOW DEVICE A/R <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture Quantily <br /> Sprinklers IV,-,(j 60 00 9 <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 to do <br /> all work in strict accordance with the ordinances of the City and State regulations, and certifies that <br /> all statements made on this application are complete, true and correct. <br /> Applicant Date <br /> Approved Approved with Corrections Denied <br /> Reviewed by: <br /> Date 9— Z 2— <br />