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' ` , ;j �� �� �i�� <br /> :�-�,;,���� <br /> �� �' <br /> � <br /> Please check one: New_� Addition <br /> ��2=ac�' <br /> JOB SITE ZCv D � <br /> Owner's Name � ep on Number <br /> Mailing Address � <br /> Sprinkler Contractor's Name , Telephone Number �S,Z-��/j .-//�G <br /> V <br /> Contact Person • <br /> Mailing Address � Li�G� ^ .S.�Jyc,f <br /> WATER SUPPLY <br /> Lake Well �_ City <br /> BACKFLOW DEVICE <br /> AVB l PVB <br /> Year of <br /> ake Model Manufacture uantit <br /> Sprinklers �G� Zo� 2� 3 <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: GPM <br /> PERMIT FEE CALCULATION <br /> 1. Permit Fee $ 3 5.00 <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 undersigned hereby applies to the City for issuance of a Sprinkler System Permit, 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 � Date �y� . �?�- <br /> � <br /> ********************************************************************************* <br /> Approved /�^�� �� Approved with Corrections Denied <br /> Reviewed b <br /> ���Ct� � �/t!,.,-�-_. Date � �� '� `�'� � <br />