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��u <br /> � �o <br /> � ' � <br /> Please check one: New _� Addition . <br /> JOB SITE I 7 � G��1��J� � �C �< �`�� ��O�1 C� <br /> Owner's Name�1 z�� JC;,<<�(��on Telephone Number�-' ��-�-� ��� <br /> MailinD Address I 7� ��--��. ��� �.��,�c�� C�C • o� o <br /> 4 <br /> Sprinkler Contractor's Name�N� ,��'����.�-���Phone Number�y �-=O�C� <br /> Contact Person �,y� �C-��n,��,� ,�� <br /> Mailing Address � �7 1 v���r,� `v(-� �t�G��o 'e 1'Y�l� �� q <br /> WATER SUPPLY � <br /> Lake Well City � <br /> BACKFLOW DEVICE � <br /> AVB PVB �� <br /> Year of <br /> Make Model anufacture ua ti <br /> �Arinklers �c�r �-��� C{� � <br /> n�o � �.X� C�x '7 �-I <br /> � � TOTAL��c <br /> �i'YDRAULIC CALCULATION Design Data: <br /> Area of Application: _ � � , 7 ���_� Sq. Ft. <br /> Coverage per Sprinkler: �T��-�— 125�- ;r. � t ���.�•- rjC 6�Sq. Ft. , <br /> No. of Sprinklers: �(�� <br /> Total Water Required: � ��,,,� ,�, �, ,,,y. �� �.,,�,� GPM <br /> r <br /> PERiVIIT FEE CALCLTT�ATION <br /> 1. Permit Fee <br /> $ 35.00 <br /> 2. State Surchar�e. $ _ .50 <br /> 3. Mail-In Fee $ _ 1.50 <br /> 4. TOTAL PERNIIT FEE (Add lines 1-3 above) $ <br /> The undersigned hereby applies to the Ciry for issuance of a Sprinkler System Permit, agrees to <br /> do all work in strict accordance with the ordinances of the City and State rewlations, and certifies <br /> that all statements made on this plicatio are complete, true and correct. <br /> . /- <br /> f. <br /> Applicant '' Date �' 11- �I`� <br /> x����������������������������*��x��ka�x����xx��X���xX��x��k���k�*x�����k����xx�k�x���x*�x��� <br /> Approved � Approved with Corrections Denied <br /> Reviewed by: <br /> ,1�-�� .�- � �- <br /> Date U � <br />