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Please check one: New Addition <br /> JOB STTE "�'/C"'� �a_, s�, <br /> Owner's Name l�,� , �c� �: = S;���-U � � �'�phone Number <br /> Mailing Address ��-ti�_,_�_ �. <br /> SprinklerContractor'sName ,�',�,;�, �,�1,�.,,z,���. ��.�� � �� � _ TelephoneNumber,i�'�-:��:�,-, <br /> Contact Person �J�� � � ��`,�'<< �� ' <br /> Mailing Address i''�� `��'��. s z�`� `�'�c - '�;�;' ���`s- <br /> WATER SUPPLY ' <br /> Lake Well _'� Ciry <br /> BACKFLOW DEVICE � � <br /> � �� ���,,.�s � 2� l� } <br /> AVB PVB � RPZ �- <br /> Year of <br /> Make Model Manufacture uanti <br /> c� Z <br /> S rinklers ' `� <br /> `�. � � � <br /> �r� � <br /> HYDRAULIC CALCULATIONS Design Data: sq. Ft. <br /> Area of Application: <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: GPM <br /> Total Water Required: <br /> � pERMTI' FEE CALCULATION $ 3.5.00 <br /> � 1, permit Fee $ _ <br /> '-� 2, State Surchar�e. � � <br /> 3, Mail-_ In Fee <br /> 4, TOTAL PERMIT FEE (Add lines 1-3 above $ ---- <br /> The undersigned hereby applies to the City for issuan e of a Sprinkler System Permit, agrees <br /> to do all work in strict accordance with the ordinance of the City and State regulations, and <br /> � certifies tha� statements made on this application ar complete, true and correct. <br /> �� � <br /> \, � � �� `�� /�, � � <br /> i J ,:_�.� �� �: Date ��_ <br /> Applicant <br /> ******�*****�****�***x��******x�**********�**** *�*x��**�**************�********� <br /> Approved <br /> � Approved with Correctio Denied <br /> Reviewe �, �i)�J�� <br /> - ��� � - Date � <br />