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Please check one: New .X Addition <br /> JOB STTE <br /> Owner's Name (��N �.�� �,5,� ; ,2 � TelephoneNumber �(�7/ , � �� `/ <br /> Mailing Address 2 � 2 � ��t 5<d ���; (z,�, <br /> Sprinkler Contractor's Name �-�-•,�,,,ZZ-� G��„r y,�,�-TelephoneNumbeY L-�Z� � l � G c,v� �) <br /> Contact Person �� .-,� �. s /C�`��.->-� <br /> Mailing Address 7 �o/ ,v,_�t��-�t s c..��j n 5S3 �'7 <br /> WATER SUP LY <br /> Lake Well City <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture uantit <br /> Sprinklers �-�,,,;�� ��,5 Z_� j c� <br /> �-�� �-,z-� /�G.� Z o" � /Z <br /> �-ic.�v(zh- ��� �cc� Z 4.� <br /> TOTAL Z � <br /> FIYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: � �S� Sq. Ft. <br /> Coverage per Sprinkler: z � Sq. Ft. <br /> No. of Sprinklers: � ;� <br /> Total Water Required: GPM <br /> PERMIT 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 /> Applicant �A��� l����_�-- � Date r� /7/ � Z <br /> ********************************************************************************* <br /> Approved � Approved with Corrections Denied <br /> Reviewed by: <br /> �1�`�l� � Date � �-�—�� <br /> � �c�5p • �Pe�e� o��rc�^ �or��lec+�: o� „ <br /> 1 <br />