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Please check one: New /` Addition <br /> JOB SITE <- /(-c"-e (,uclZc0- <br /> Owner's Name Telephone Number <br /> Mailing Address <br /> Sprinkler Contractor's Name ( ','6',774'-' (---7",e, Telephone Number 6 1 L- --/—j ] r0) <br /> Contact Person j X, C t,..) 1 <br /> Mailing Address / �1 ��1._ �.r�9r ��� ,t � i�!1,��-� >,�� ��y� <br /> WATER SUPPLY <br /> Lake Well City <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture Quantity <br /> Sprinklers '( p <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: 1 2 Sq. Ft. <br /> No. of Sprinklers: <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) $ 77. o <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 an this application are complete, true and correct. <br /> Applicant _ Date `.. 1 7 / <br /> Approved A Approved with Corrections Denied <br /> Reviewed by: <br /> Date ?—/6 ?/ <br />