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�ec� <br /> 1� <br /> � � <br /> � , ��� ����- <br /> Please check one: New Addition � -Q <br /> • r� <br /> � � <br /> JOB srrE � � � ,(�_.�� ' ��� y � , ` �� 3 <br /> Owner's Name� ��i�-��^��'�1 TelephoneNumber V/ <br /> Ma�ing Address <br /> Sprinkler Contractor's Name ��'s�r�4 a.� � �, �5��,,.� Telephone Number �(; �j • � �y-7��� <br /> Contact Person � _ �, �,-� �„C. 1 � <br /> Mailin?Address _ 7 �{ ��7� r�> L��� /-( t, � !Uv v� ' <br /> �VATER SUPPLY �•t� ,� ( � <br /> Lake Well City_� � r.� T �� 3 - �(� 1 � <br /> BACKFLOtiV DEVICE . / - <br /> AVB PVB V <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers �_� -�, ( o�•- �'���-� � G'tl ( �{'7— 'T <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: <br /> Total Water Required: � � G t''� Gp� <br /> PER�I�IIT FEE CALCULATION <br /> 1. Permit Fee $ 3 5.00 <br /> 2. State Surcharee � .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. TOTAL PER1l�IIT 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 /> all w�ork in strict accordance�.vith 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 � �� � r �' � <br /> ************�******�*****�****************************************�************** <br /> Approved X Approved with Conections Denietl <br /> Reviewed by: �1„_ � <br /> �°r� Date 7'3- � 1 <br /> — r�o RPZ. qllowec� <br />