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logy <br /> Please check one: New Addition <br /> JOB SITE 4.04XL) ��� cJ <br /> Owner's Name <br /> ic I Telephone Number <br /> Mailing Address ' ) <br /> Sprinkler Contractor's Name/1,,, e s e/c,/ �,f je Telephone Number 6“/ <br /> Contact Person (Dv- I 0 vti <br /> Mailing Address h /7 iO . <br /> WATER SUPPLY <br /> Lake Well City <br /> BACKFLOW DEVICE <br /> AVB PVB )( <br /> Year of <br /> Make Model Manufacture Ouantity <br /> Sprinklers (l,t icy- A eiCN //c,•,./ <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: (726e..-0 Sq. Ft. <br /> Coverage per Sprinkler: /cr v Sq. Ft. <br /> No. of Sprinklers: 3„Z <br /> Total Water Required: / 3 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) $ 70a (� <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 de on this, plicatio complete, true and correct. <br /> Applicant �- /�� <br /> PP Date <br /> **********************k*** .******$e*%k****$e******X*****3eieaeaege3,e(e;esc3,e3,e*****3,ex***** <br /> Approved Approved with Corrections Denied <br /> Reviewed by/ <br /> • /' �'� sem!' Date 7'9'9? <br />