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� � �,,��'(� <br /> Please check one: New Addition ✓ <br /> JOB SITE �o-�- �X_r.���h <br /> Owner's Name ��J ,�)�y..P z,� � Telephone Number <br /> MailingAddress_ _2 � °7 0 ��o��.�ti�-,� cx� �-2�y,� G` �=�- <br /> Sprinkler Contractor's Name �Z� Telephone Number �-��- ��j� <br /> Contact Person � � C, � . - ��_ <br /> Mailing Address_ l� C� �� U �—�--�� � �����/� l� GC �'Yl , /�� N J".�Z/�( <br /> �ATER SUPPLY <br /> Lake Well � City <br /> BACKFLOW DE�—E <br /> AVB -�,,� PVB <br /> Year of <br /> ake Model Manufacture uanti <br /> SDrinklers L�,.c��/�^,t l-�r��'� � � , <br /> TOTAL � <br /> HYDRAULIC CALCULATION Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: � �` ' Sq. Ft. . <br /> No. of Sprink.lers: <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 undersianed 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 rewlations, and certifies <br /> that all statements made on this application are complete, true and correct. <br /> . _�-�� <br /> Applic�� ��--- �' �� Date �� 3�' r� <br /> �k�k=k�k�k�k���k��k��k���K�k����k�k��k���k�k��k��k�kX�k��kX?��k�?<��k�;cxs;c�;e�x�k�k�k�k=l��k*M�k�k��k�k���k��k���k�kK*�k�FX� <br /> Approved Approved with Corrections - Denied <br /> Reviewed by: /, <br /> � <br /> Date ���-�_ � <br />