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Please check one: New � Addition <br /> � <br /> JOB STI'E � " `J� � <br /> Owner's Name Telephone Number 5�,��" - �U 7-� <br /> Mailing Address <br /> Sprinkler Contractor's Name� "� Telephone Number .<,--�� -d��(d <br /> Contact Person � -�- <br /> ;�`� .. <br /> Mailing Address f � .� � -' ' a <br /> WATER SUPPLY ' �5�05 <br /> Lake Well _�___ City <br /> BACKFLOW DEVICE <br /> AVB PVB � RPZ <br /> Year of <br /> Make Model Manufacture uantit <br /> S rinklers , ' � <br /> � -, <br /> TOTAL <br /> HYDRAULIC CALCUI.ATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: <br /> Total Water Required: GPM <br /> PERMIT FEE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> 2. State Surchar�e. $ .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 issuanc 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 made on this application ar complete, true and correct. <br /> ; .� _�J � - � � � sy <br /> Applicant r`--- ?"""- Date �.�� ��r <br /> ********�x******** ***********�**********�**** ****�*************��x�*********** <br /> Approved Approved with Conectio Denied <br /> Reviewed by: � <br /> Date �r� <br />