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C � <br /> Please check one: New " Addition <br /> JOB S�_ � 6 � a ,�� �,s .�� � �J <br /> r , <br /> Owner's Name � �� cJ �' %/" TelephoneNumber `� 7� � �j /G <br /> Mailing Address �,�i")'�� <br /> Sprinkler Contractor's Name �'�S C� ,�,�'/`, ti� f(,�J� TelephoneNumber_�5��- � � `� � <br /> Contact Person ,�✓`;,z ;,� � � ( <br /> Mailin�Address /D�� �2 n�a� �0 i/� , ,�, � <br /> �VATER SUPPLY � <br /> Lake `Vell City <br /> BACKFLO`V DEVICE - <br /> AVB P VB �_ <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers � �o�J ,Fi�o 6„�� /y� S S6 <br /> /�.A.^� ��� /��r'y / `� `i � C' <br /> TOTAL �i <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Covera�e per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: <br /> Total Water Required: Gp� <br /> i��ITIT'�'EE CALCULATION <br /> 1. Permit Fee � 3 5.00 <br /> 2. State SurcharQe � .50 <br /> 3. Mail-In Fee � 1.50 <br /> 4. TOTAL PER1tiIIT FEE (Add lines 1-3 above) $ 35', SQ <br /> The undersi�ned hereby applies to the City for issuance of a Sprinkler System Pernut, a�rees to do <br /> all�vork in strict accordance�vith 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 ./v� Date � - � " � � <br /> *******************�***�***** **********�******�********************�************ <br /> Approved pproved with Corrections Denied <br /> Reviewed by: " <br /> Date `�— 9-�v <br />