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. ��u,���� �3 y 3 � <br /> ' 3m. S <br /> ?lease chec one: ��New Addition <br /> _ , <br /> JOB S I TE 7 c�—.� '� � � � � � � �"'�` � �� G�L�YI� <br /> O:arier' s Name c� ' Te lephone Number �7� ` �J� 7� <br /> - � , ' � � �?�- i1� ����, � -4 <br /> Mailing Address - <br /> Sprinkler Contractor' s Name �l�c��?�,Telephone Number ,,�,� ���� <br /> F � <br /> Contact Person <br /> � � � � � , � � . � ��� <br /> Mailing Address � <br /> **�*****�*�*****� �**** * **** **:*�***�**** ***�* �r *** *�*************** <br /> CLASSIFICATION OF OCCIIPANCIES <br /> Commercial Residential %� <br /> *********f�*�**�***�******�***�*********t*t*t*****�:****�***:**���*�*�***tf <br /> WA�ER SIIPPLY � <br /> Lake Well City <br /> **************�********�*�***********�**�****t********t***********�*�**�*** <br /> Year of Orifice <br /> Make Model Manufacture Size Quantity <br /> S�rinklers "%c�� � 7L[� l� �� � `T`� I .�-5 C,P�� ,� c- <br /> TOTAL :� C� <br /> *#****��****�t�t*�*************���***********t*�*t**�*******�*���**�r******��� <br /> E�Dp,p,QI,IC CAi,CIILATIONS Design Data: <br /> P_rea of Application: � 3 (i Sq. Ft. <br /> Coverage oer Sprinkler: '�f "/ �3c1, �� S __ Sq. Ft. <br /> No. of Sprinklers : <br /> Total Water Required: ✓ 7 GPM. ;�� ✓ ��� �'� ''` Z ` '` `_� <br /> *�t**�t��t**t*�*�r*********�***�*f***�*****t*****�******�**t�t�t*��****t*******�* <br /> PERMIT FEE CALCIILATION <br /> � . Permit Fee $ 30 . 00 <br /> 2 . State Surcharge. Based on valuation. $ . 50 <br /> 3 . Mail-In Fee $ 1.50 <br /> d . TOTAL PERMIT FEE add lines 1-3 above $ <br /> The undersigned hereby applies to the City of issuance of a Sprinkler <br /> �ystem Permit, agrees to do all work in strict accordance with the <br /> ordinances of the City and State regulations, and certifies that all <br /> statements made on this application are complete, true and correct. <br /> ��p ' - "" �� - <br /> �`- � Date =� �-�=�-- <br /> Applicant � �Z-� �� �._ : -,,�., � �. �' <br /> ����������****************�**�r****************�**************** ********* <br /> Approved �� Approved with Corrections Denied <br /> Reviewed by: <br /> ���f � � <br /> 5�`�� <br /> Date <br />