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Please check one: New Addition �� ��V�O � <br /> JOB SITE �,�� .��. �����F.� &�,�,� y� <br /> Owner's Name__��� ��,��t�r Telephone Number ��; C.� 7,�i'',� <br /> y,�. :y�p�. <br /> Mailing Address � �":� �_� ;. 4� � � .� � <br /> Sprinkler Contractor's Name ��M�°�k� • '���,.--Telephone Number �,�' ,� <br /> Contact Person ��„��'�` v�` �` <br /> MailingAddress °"��:.��� +�;��;��p.�-:re r� :;r� �:��. ,.... _ ,/�,r*���. u �:-�'' � �����°` <br /> WATER SUPPLY <br /> Lake Well s✓r� City <br /> BACKFLOW DEVICE <br /> AVB PVB �� <br /> Year of <br /> Make Model Manufacture Ouantitv <br /> Sprinklers f�:.'�.::�• �, ��:�� �' �J <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: �� ' Sq. Ft. ,_ <br /> No. of Sprinklers: �'r;� <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 <br /> do all work in strict accordance with the ordinances of the City and State regulations, and certifies <br /> that all statements made on this application are complete, true and conect. <br /> .� <br /> . - � '�� <br /> Applicant � � �1� � Date ���� <br /> ���*�x*�x��x����x��x��x*�x���x�x�*����*��a���*��*�x��*�**�x*x���*����x���x��xx�����xx��x�*x��*��� <br /> Approved � Approved with Corrections Denied <br /> Reviewed by: _.-� <br /> � ..�` - �� Date ,'"'�� <br />