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Piease check one: New� Addition <br /> JOB STTE _ ���� �'�2, /� ��, r/� <br /> �. <br /> Owner's Name J�/� �ZJ�� � TelephoneNumber 9�Z `�j/-���l <br /> Mailing Address � � 3��`�' � � ��� 5� ��� �� � � <br /> Sprinkler Contractor's Name TelephoneNumber <br /> Contact Person <br /> Mailin�Address � <br /> �VATER SUPPLY � <br /> Lake Well City <br /> BACKFLO`V DEVICE <br /> AVB ` PVB <br /> Year of <br /> Make Model Manufacture uanti <br /> Spr�inklers %'��-z> z�.� / z.� <br /> TOTAL <br /> HYDRAUI.,IC CALCULATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coveraae per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: <br /> Total Water Required: Gpu <br /> PER�I�IIT FEE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> 2. State Surchar�e $ .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. TOTAL PERNIIT FEE (Add lines 1-3 above) $ _3-,. �Z� <br /> The undersigned hereby applies to the City for issuance of a Sprinkler System Pernvt, 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 � �Z'1 /�l' -- �- Date �/y-U / <br /> ************�k*'******************************************************************* <br /> Approved i' Approved with Corrections Denied <br /> Reviewed by: <br /> " Date ����t '� � <br />