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���� _ ; ����q/ <br /> Please check one: New �/ Addition <br /> JOB SITE <br /> Owner's Name '— ° � � Telephone Number���2� �1�/- 9.30� <br /> Mailing Address 31.3 3 �1�'LC� Z 0 %/I�`�2� /��//(� 3�� <br /> ,� <br /> Sprinkler Contracto�s Name ��� �� ,����,h�1 i� TelephoneNumber�9Sd���(�-/��� <br /> , <br /> Contact Person � � % �� y�y� <br /> ! , <br /> Mailin�Address ' �-�2 L "z 6�z[ � /y T/�' r ' <br /> `VATER SUPPLY <br /> Lake�_ `Vell City <br /> BACKFLO`V DEVICE • <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers <br /> TOTAL <br /> HYDRAULIC CALCITLA'TIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coveraje per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: <br /> Tota1 Water Required: Gp� <br /> PER�'VIIT FEE CALCULATION <br /> 1. Permit Fee $ 3 5.00 <br /> 2. State Surcharse $ .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. TOTAL PER�tiIIT FEE (Add lines 1-3 above) $ <br /> The undersi?ned hereby applies to the City for issuance of a Sprinkler System Pernut, a�rees to do <br /> alI 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 /> Applicant � �� ^ Date � l� /Q o2 <br /> *****�******�***************** �*�****�*************************�*****�***�**** <br /> Approved � Approved with Corrections Denied <br /> Reviewed by: <br /> �� Date 5-�y-o � <br />