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�(� � 02� <br /> Please check one: New �/ Addition <br /> JOB SITE �m� <br /> Owner's Name Q/1'�.� Telephone Number <br /> MailingAddress 9�' G�'J � /�1D /V �,3s9 <br /> Sprinkler Contractor's Name�l I t/�er�'elephone Number ��o���� <br /> Contact Person <br /> Mailing Address �9� � O�dL �ox-�c� /V ���� <br /> WATER SUPPLY / <br /> Lake Well ✓ City <br /> BACKFLOW DEVICE � <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture Ouantity <br /> S rinklers <br /> � <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: <br /> Total Water Required: GUe�y�q.�cr� a GPM <br /> PERMIT FEE CALCULATION �y ���1� �� G P�� <br /> 1. Permit Fee $ 35.00 <br /> 2. State Surcharge. $ .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. TOTAL PERMIT FEE (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 /> Applicant � Date ����— 9� <br /> **�**�*x�**x�***�**************�****** �*��*x�****�***�***�x*����**�*****x�*�***�� <br /> Approved � Approved with Corrections Denied <br /> Reviewed ' <br /> "".� _ �c�� <br /> Date <br />