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�-/�-05' <br /> Aa 8�i� <br /> Please check one: New � Addition <br /> JOB STTE �U�, �0.�I S 1 d G t�r-� <br /> Owner's Name (,i C� �-,;��c-1 Telephone Number %S��f�''j' �v�) <br /> Mailing Address r 5: �c� ��, (�r�. �,�, <br /> Sprinkler Contractor's Name r Telephone Number 71��-�.J�j- � �� <br /> Contact Person V <br /> MaiLng Address,-r�I i�5 �PY��►S�r'ia l ��Y'( �- m Q n)r Y � ;n , lrYl� �53�_ . <br /> `VATER SUPPLY <br /> La.ke Well � City <br /> BACKFLOW DEVICE � <br /> AVB P VB <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers -}� r`.� ( 1'Z(S Cc��� v � r'z, <br /> , <br /> `t�V J�.'�E r �- f� ._ ��;i����,� �;� 1 b <br /> - TOTAL (,,� <br /> r <br /> HYDRAULIC CALCITLATIDNS Design Data: <br /> Area of Application: "f�,5�� S Ft. <br /> q- <br /> Coverage per Spn�:�er: _r����� j'�,��� �Dr���.� ( i 5 Sq. Ft. <br /> No. of Sprinklers. ��ZJ �`fi- �� <br /> Total Water Required: �� Gp� <br /> PERMIT FEE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> 2. State Surchar�e $ .50 <br /> 3. ivlaii-In r ee $ 1.50 <br /> 4. TOTAL PERl�IIT FEE (Add lines 1-3 above) $ ' '' r.� <br /> The undersi�ned 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 application are complete, true and correct. <br /> � <br /> ; <br /> Applicant '�'"" �, Cc�---�., Date � 1 <br /> 1 05 <br /> ********************************************************************************* <br /> Approved__Q�_ Approved with Corrections Denied <br /> Reviewed by: n <br /> d' l""``_. Date Y- Z►- v 5� <br />