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�j <br /> , - t,�� <br /> ; , �' <br /> Please check one: New X Addition �- <br /> JOB STTE ��� Ib�ccc�C-��C,; � <br /> Owner's Name � �: �E'Et-X... TelephoneNumber �l7�-- `�Z6� <br /> Mailing Address 1 Sb� d��ec�� ��-- �c�1� <br /> Sprinkler Contractor's Name �����n�X S�,.hJC(Q�, TelephoneNumber ��7Z--j�+/�j <br /> Contact Person � � �vP_� , <br /> Mailing Address _ %5�7� 1��' S�� �.t•�-��w r�_ ,�i,�- S���O ' <br /> `VATER SUPP Y <br /> Lake Well City <br /> BACKFLOW DEVICE <br /> AVB PVB <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 /> PERiI�IIT FEE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> Z. State Surchar�e � .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. TOTAL PERII�IIT FEE (Add lines 1-3 above) $ 3�;: S�} <br /> The undersi�ned 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 � Date_�'/3-(�C� <br /> --z <br /> ****************************************�**************************************** <br /> Approved Approved with Corrections Denied <br /> Reviewed by: '' <br /> � u� Date h `- /�- �C� <br />