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Please check one: New � Addition <br /> JOB SITE �� ��j � p�� /�v•� 1�c� r � <br /> Owner's Name �,(J��� ��� (,(i Telephone Number �v%� �'l 3 7 � <br /> MailingAddress S,�rt�,� <br /> Sprinkler Contractor's Name �p� �}-� �,vca � Telephone Number('%Z.� 7�'C �~ZIOG <br /> —"�� Contact Person �, c�i �•� � ..o <br /> Mailing Address `7� � �� L,..rJ�/�P�� l� ������'-� �Uv �h��..e�� �9� <br /> WATER SUPPLY S 5��� S� <br /> Lake Well � City <br /> BACKFLOW DEVICE <br /> AVB PVB � <br /> Year of <br /> Make Model Manufacture uanti <br /> S rinl:lers � ' O <br /> `'''u��� �"7r"J�,� � cl'c� S� `y <br /> TOTaL� � <br /> HYDRAULIC CALCULATIONS Design Data: :5�--�f�'�n-� <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: <br /> Total Water Required: ��, GPM <br /> PERMIT FEE CALCULATION <br /> l. Permit Fee $ 35.00 <br /> 2. State Surcharge. $ .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. TOTAL PERMIT F'EE (Add lines 1-3 above) $ <br /> The undersigned 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 regulations, and certifies <br /> that all statements made on this application are complete, true and correct. <br /> I1, <br /> Applicant �'f/ Date � � �' <br /> �***�*�x�*x�***x�*�**�**�********��***�***���*�***x��**�***�*�***x��x**�x*******�***� <br /> Approved �J Approved with Corrections Denied <br /> Reviewed b • � " <br /> � � � , � <br /> �� �� i' � � �!� `��'�_----� Date ���� <br />