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Please check one: New� Addition <br /> JOB STTE d � ��o�--��� �� `S , <br /> Owner's Name s�-{ � � (a�h �� Telephone Number <<� � �'��S � <br /> Mailing Address � y �' � 4 � ��� . <br /> Sprinkler Contractor's Name �-� S ���"�-� ��_ Telephone Number ��1 — G��2 <br /> Contact Person �� �� � c � <br /> Mailing Address !' � �o � � � G � �f�;� /�1 �1 - S S .� � . <br /> `yATER SUPPLY <br /> Lake Well� City <br /> BACKFLO`V DEVICE <br /> AVB P VB� <br /> Year of <br /> Make Model Manufacture u nti <br /> Sprinklers �� �l`�'<<— � � v�,c� <br /> c i'� '��' � �U c:2�2� � <br /> TOTAL <br /> HYDRAULIC CALCUI,ATIONS Design Data: <br /> Area of Application: ���'�' Sq. Ft. <br /> Covera�e rer Srrinkler. � Sq. Ft. <br /> No. of Sprinklers: � <br /> Total Water Required: _ � d Gp� <br /> PERi1�IIT FEE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> 2. State Surchar�e $ .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. TOTAL PEI2itiIIT FEE (Add lines 1-3 above) $ �35; 5•� <br /> The undersigned hereby applies to the City for issuance of a Sprinkler System Pernut, 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 pplicati are complete, true and correct. <br /> / � � � <br /> Applicant C� � Date (� �G C,G <br /> ************�********** *�*******�********************************************** <br /> Approved Approved with Conections Denied <br /> Reviewed by: � �� <br /> Date (� �Z o •-oc� <br />