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Please check one: New_ ; Addition <br /> JOB srrE I��� �r c����s �-�� (�cQ, <br /> Owner's Name _ �p�L �c.�rr c_� Telephone Nurnber Y7,S—�133 <br /> u - <br /> Mailing Address_ �w�P � <br /> . . . <br /> Sprinkler Contracto�s Name �r�ess<an� S��nk-�,e,� TelephoneNumber �'SZ- �I�Z�/9�� <br /> Contact Person �� ��.s��;,�. <br /> Mailin?Address _ 1 Szl�S� f��'�' S`�� l-�.�-er•lo�.,�� � ,/t�,�. SS 3 c�� � <br /> `VATER SUPP Y <br /> Lake Well City <br /> BACKFLO`V DEVICE - <br /> AVB P VB <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers <br /> TOTAL <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 /> PER1ti1IT FEE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> 2. State Surcharse $ .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. TOTAL PERiI�IIT FEE (Add lines 1-3 above) $ <br /> The undersi�ned hereby applies to the City for issuance of a Sprinkler System Permit, 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 /> Applicant Date_ ��•� <br /> ************�*************�*************�*************************�************** <br /> Approved n Approved with Corrections Denied <br /> Revie�ved by: ` <br /> �v�i� Date �— �" (� <br />