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Please check one: New /7 Addition <br /> JOB SHE O7 / 9 /9."6,461,,e ,e e , <br /> Owner's Name <br /> lee!/ � ( ( 4.,,, - 4cidiZ.Z' Telephone Number 4/7/-fa? <br /> Mailing Address ,i 99,$'A14 2S CiPZ #--,7 65 33/ <br /> Sprinkler Contractor's Name Lfimilitthix4 a4efelephone Number I/77-5;Z <br /> Contact Person leg c9-1 4,,i)t.A.A. <br /> Mailing Address Po. ,& c/6.03 1214,72e2446 141/2 55i`'t <br /> WATER SUPPLY/ <br /> Lake f Well City <br /> BACKFLOW DEVICE 6// 11d- <br /> 4-6 <br /> AVB PVB RPZ <br /> Year of <br /> ' <br /> Ma Model Manufacture` Quanti <br /> Sprinklers ayeitiallii.e" .44;4- 19P ) �i i'' t 0 <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: iZ‘746Zr Sq. Ft. <br /> Coverage per Sprinkler: VC Sq. Ft. <br /> No. of Sprinklers: 09' <br /> Total Water Required: CO i '• s . , 4t M <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 <br /> to do all work in strict accordance with the ordinances of the City and State regulations, and <br /> certifies that all statements ma on this application are complete, true and correct. <br /> Applicant I:ka "I / DateY''7_,1,4****************** ********************************************* *********** <br /> Approved 1 Approved with Corrections Denied <br /> Reviewed 9,,,: _. 9>—A <br /> Z.17 <br /> �� �,`�L/ - . Date _ <br />