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, Please check one: New �1' Addition <br /> JOB STTE <br /> Owner's Name_�Te.,���.,,+(�r Q, �r>'y�G� h���- TelephoneNumbe ���� ��'��� <br /> Mailing Address �'��� (,Q� �� ; , ��r. �`�'' ��i� <br /> Sprinkler Contractor's Name ��S�'� y��'$1e.-5 Telephone Number � �.\e� -1.� �L�� <br /> Contact Person '�►' e�a <br /> Mailing Address " ��" � <br /> `VATER SUPPLY � <br /> Lake Well � City <br /> BACKFLOW DEVICE .� <br /> AVB PVB�``� <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers _ 1-�v���x v <br /> , <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler; Sq. Ft. <br /> No. of Sprinklers: 'Z(� <br /> Total Water Required: 1� 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) $� '�,c�:7 <br /> The undersigned 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 /> �,�.-.�.—�:.� l � . <br /> Applicant Date �9���'C�L�� <br /> ******************�************************************************************** <br /> Approved /`"� Approved with Corrections Denied <br /> Reviewed by: � <br /> Date �'�� Q� <br /> C ��� t"P( �(���t L��G'� ��4-� t�^�I'��� <br />