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�;�'!nC `�� � , j� <br /> � ' ���� J� <br /> , <br /> Ple,�se check one: New�_ Addition <br /> � JossrrE D� o�n C_ SCv � r ,� CLC <br /> Owner's Name �[;, ��M R�� r�a'1�E �S j'�G. � Telephone Number <br /> Mailing Address `?� �3 C� S'C'D �� ('��_C��-���� <br /> ���r�/ <br /> Sprink1er Contractor's Name T� /� �'� TelephoneNumber���–�7 �=' <br /> Contact Person (� ,�,�� <br /> Mailing Address�7�� �{/���. /� �l c� �����—���- �'' ��—�.^��...� � <br /> `VATER SUPPLY <br /> Lake�_ Well City <br /> BACKFLO`V DEVICE - <br /> AVB P VB <br /> Year of 2 <br /> Make Model Manufacture uanti <br /> Sprinklers c� t – � g' �!nc� � �� �a' � � <br /> � <br /> TOTAL <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: Gp� <br /> PERi1�IIT FEE CALCULATION <br /> 1. Pemut Fee $ 35.00 <br /> 2. State Surcharee $ .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. TOTAL PEItlti1TT 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 /> 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 /> Applicant �. v��� �'p,�/i�-2 Date ' <br /> *****�***�**�****�**�****�*********�*******************************�**�********** <br /> Approved Approved with Corrections Denied <br /> Reviewed by: (�� <br /> ' ►y\� � Date �-��-D � <br />