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( <br /> Please check one: New_�Addition <br /> JOB STTE /po �r-i s�� ���- �' � r <br /> Owner's Name 1YJ�,,,!� l-���,,,�„ ,, a, � � Telephone Number <br /> Mailing Address l v ��t,�/ l' ..`�,�_� �6 <br /> Sprinkler Contractor's Name�c �/ �c,�,�,� TelephoneNumber_ y� q_aS �,S <br /> ContactPerson ��� rrr ,_� <br /> Mailin?Address � G �� r J'�..,,,, �S'tit G�� 4'Y�t,,� /�/.�,.; � <br /> `VAT'ER SUPPLY <br /> Lake `Vell ��City <br /> BACKFLO`V DEVICE - <br /> AVB Pvg �� <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers �.,,�,r �G.o ��ao Go <br /> R.►iwd./� !J I`!/1 �• �CG � <br /> TOTAL <br /> HYDRAULIC CALCITI.ATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Covera�e per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: Gc� <br /> Total Water Required: _ /,s'•�r� GPM <br /> PEFtivIIT FEE CALCULATION <br /> 1. Permit Fee $ 3 5.00 <br /> 2. State Surchar�e $ .50 <br /> 3. Mail-In Fee Q <br /> , �„ <br /> �-r.�o-- <br /> 4. TOTAL PERirIIT 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 /> �,'. •��;ork in strict scco:�:.:;,;, -:.;"-;the ordin��ces oi tne City and State reguiations, and certifies that <br /> all statements made on this application are complete, true and correct. <br /> Applicant / ` Date �=/-vv <br /> ********* **** *************�*******�**************�************************* <br /> Approved Approved with Corrections Denied <br /> Reviewed by: � <br /> �J " Date S�;-2—� <br /> '� 1�dar-fioy�l �a���t r��u���/ � �r��� r/�cJ �o�2��E�21�8�Z � <br /> C!� <br />