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I ) <br /> Please check one: New_ Addition <br /> JOB SITE ru�, 4,, // ,k 1�'a j ►1 <br /> Owner's Name � ; �?- 0 C, S fi Telephone Number 7 SIQ <br /> Mailing Address �6 jL,1( 4,`/4- -, ; <br /> Sprinkler Contractor's Name At',e w Telephone Number <br /> Contact Person J' l C• -N <br /> Mailing Address <br /> WATER SUPPLY <br /> Lake Well City <br /> BACKFLOW DEVICE <br /> AVB PVB y� <br /> Year of <br /> Make Model Manufacture Ouantitv <br /> Sprinklers <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: —SC)C)C,, Sq. Ft. <br /> Coverage per Sprinkler: /4�)C Sq. Ft. <br /> No. of Sprinklers: 3 v <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) $,_31d d <br /> . <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 a plication a complete, true and correct. <br /> Applicant N Date 1161/11 <br /> PP <br /> Approved Approved with Corrections Denied <br /> Reviewed by: <br /> Date <br />