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� <br /> . <br /> Please check one: New _� Addition <br /> JOB s� 28�0 �.��- ��,., ��, 1 <br /> Owner's Name � � �� �� Telephone Number <br /> Mailing Address Z�(,,� �er- ��.�'I�.�, � <br /> Sprinkler Contractor's Name -�-��-}-�a„ �csc��,e c�'S Telephone Number 5�G ��S�/8 <br /> Contact Person � ��� � ��C ��c- - <br /> Mailing Address �� �o x � �',�� P �.S/o r' �/�f l�+ SS 3`� 1 <br /> WATER SUPPLY � <br /> Lake Well `/ City <br /> BACKFLOW DEVICE / <br /> AVB PVB // RPZ <br /> Year of <br /> Make Model Manufacture Quantity <br /> �rinklers �iPD �U 0 / �5'S Z�- <br /> �� �� �570 l9Ss <br /> TOTAL 'a, t <br /> HYDRAUI.IC CALCULATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: -� � : 7 Z°'N�.s <br /> Total Water Required: /� G Ptir 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 undersi he y applies to the City for issuance of a Sprinkler System Permit, agrees <br /> to do all w rk i r' t accordance with the ordinances of the City and State regulations, and <br /> certifies t at all at ts a e n this ap on are complete, true and correct. <br /> � <br /> Applicant Date �-/3 ' �_ <br /> ***********�*************�********�****��***�*****�**�***********��*�x�***�**** <br /> A roved Approved with Corrections -�'�-- Denied <br /> pP <br /> Reviewed by: � �� ��� ,�y� <br /> � �� Date `�� <br />