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, <br /> Please check one: New �/ Addition <br /> JOB STTE I� � � �jG ���S �7` �� <br /> Owner's Name � �� � ( �'c r►� ��P }-�- TelephoneNumber � �% �S 3� <br /> Mailing Address � �c�5 h�� <br /> Sprinkler Contractor's Name �. /'nc. :>.e -v -� TelephoneNumber -- ! G� ���:2. <br /> Contact Person �- � �,,- �, , <br /> Mailin?Address � 6 c� 3 c, Z.,, r - • <br /> `VAT'ER SUPPLY <br /> Lake� `Vell City <br /> BACKFLO`V DEVICE - <br /> . . AVB PVB <br /> Year of <br /> Make �, Mo el Manufacture uantitv <br /> Sprinklers �'h�c� G 6pa <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: (/ <br /> Area of Application: _ �7G�'� Sq. Ft. <br /> Covera�e per Sprinkler: _ /O � Sq. Ft. <br /> No. of Sprinklers: <br /> Total Water Required: Gp� <br /> PER.�tiIIT FEE CALCITLATION <br /> 1. Permit Fee $ 3 5.00 <br /> 2. State Surcharse � .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. TOTAL PERitiIIT FEE (Add lines 1-3 above) $ 3 5�� 5U <br /> The undersigned hereby applies to the City for issuance of a Sprinkler System Permit, agrees to do <br /> all�vork in strict accordance�vith the ordinances of the City and State regulations, and certifies that <br /> all statements ma on this ap 'cation ar complete, true and correct. <br /> Applicant ;l' Date <br /> *********�***�********** *x�*�******�***************************��************** <br /> Approved /� � Approved with Corrections Denie� <br /> Revie�ved by: ' <br /> �l�d �l�G�� Date g'l5--pC� <br />