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Please check one: New Addition <br /> JOB SITE <br /> Owner's Name /``,1A I- , &A Do r r Telephone Number <br /> Mailing Address ,2�:A J/CA UJ A ��`, m 0A. o <br /> Sprinkler Contractor's Name _,4�6c f p f ;�,� e y-' Telephone Number <br /> Contact Person /`a, / <br /> Mailing Address &VE, jE If p,'e. I"]►� �S�7 <br /> WATER SUPPLY / <br /> Lake Well t. City <br /> BACKFLOW DEVICE / <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture Quantity <br /> Sprinklers 1A+e ;is ,) As lar C 0 6 / <br /> 41y-0 a P—) 74" �g 9 <br /> .'c .Sp rA til 7 <br /> TOTAL- 3 <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: ?0 0 Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: <br /> Total Water Required: /o 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 l �� <br /> Approved Approved with Corrections Denied <br /> Reviewed b <br /> /v/ Date <br />