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Please check one: New �✓ Addition <br /> JOB STTE <br /> Owner's Name ���C l ' OGU P� Telephone Number �i/-;�o?/� <br /> � Mailin Address� `� <br /> g /4�� ��s�c� �i�r��� �������i��( , i1��� .5..5-39/ <br /> S rinkler Contractor's Name � <br /> P � �/-�i�7�rl�r �1�i�1 TelephoneNumber ���-'/%�� <br /> / ' S�r�'��f'P/�S�Lr�C, <br /> Contact Person .�`��,D�' �;��ry��7 <br /> Mailing Address ��'7�C� /:f/���1��;� �r� �'C���i�<'> /�'7/U <—-�'��� . <br /> `VATER SUPPLY <br /> Lake_,� Well City <br /> BACKFLOW DEVICE <br /> AVB P VB <br /> Year of <br /> Make Model Manufacture uantitv <br /> Sprinklers <br /> TOTAL <br /> HYDRAULIC CALCITI,ATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: <br /> Total Water Required: Gp� <br /> PERIVIIT 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 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 /> ......_._.J ��-1 <br /> � ( � <br /> Applicant ��, � Date J -�-0� <br /> ************.********************* ********************************************* <br /> Approved /' Approved with Corrections Denied <br /> ; <br /> Reviewed by: �. • `� <br /> !�J ��� Date J� --.�-a V <br />