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Please check one: New� Addition <br /> JOB SITE �� ��C �/�f�.C) C�/� <br /> Owner's Name �/z�C �I P/° Telephone Number ���' /� y� <br /> Mailing Address ��l� G C,9SG 0 C/2� <br /> Sprinkler Contractor's Name,��t//1, L/C.�%�.�4 7/0� TelephoneNumber ���� ~O��`� <br /> Contact Person ,�j�,,,�; ,l/�h-•>�/c_S�-- <br /> Mailing Address %%3 L��/�-� c._ ,-,. �/-�/��c����- /'�r--� . <br /> `VATER SUPPLY <br /> Lake Well City <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers �/< � �.-� a o ,�a b� / <br /> TOTAL j � <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: <br /> Total Water Required: � b GPM <br /> PERIVIIT FEE CALCULATION <br /> 1. Pernut Fee $ 35.00 <br /> 2. State Surchar�e $ .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. TOTAL PERiI�IIT FEE (Add lines 1-3 above) $ <br /> The undersi;ned 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 conect. <br /> Applicant ������ � G��'�Jgs�`y'�vt— Date �`'-n1 F 'v 6 <br /> ************ **********� * *******************�********************************* <br /> Approved proved with Conections Denied <br /> � <br /> Reviewed by: ��� <br /> Date �r�-$ '�J <br />