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Please check one: New Addition — <br /> JOB SITE_ //4'4 - <br /> Owner's Name <br /> 15 4X t! /ku lG - <br /> To Number <br /> - - <br /> Mailing Address , //U/) "Tr k� �ac� rra itAy'-r' "�5 <br /> Sprinkler Contractor's Name ,QTyr„mac. ;elephoneNumber�3�5',5!-DZ <br /> Contact Person iY <br /> Mailing Address2_� ��rr�`!, �r sn /bac/ [car,.s Ga �.e /tl•C-�.��S �'� <br /> WATER SUPPLY <br /> Lake _ Well City <br /> d <br /> BACKFLOW DEVICE / <br /> AVB- P VB <br /> Year of <br /> Make Model Manufacture Quantity <br /> Sprinklers A[&.-y oee,, 4n ,.0 Z R <br /> 4 410 <br /> TOTAL 4,? <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: S, dpd Sq. Ft. <br /> Coverage per Sprinkler: �o��s �o ' �nr /S' Sq. Ft. <br /> No. of Sprinklers: l R <br /> Total Water Required: Zp GPM <br /> PERMIT FEE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> 2. State Surcharge $ 50 <br /> 3. Mail-In Fee $ <br /> 4. TOTAL PERMIT FEE (Add lines 1-3 above) _ $ 3S. 5D <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 /> ********************************************************************************* <br /> Approved PAR Approved with Corrections Denied <br /> Reviewed by- <br /> NAM, <br /> y: <br /> � - - - - _ - <br /> — r _ <br />