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. , AO�� �-� <br /> Please check one: New `� Addition <br /> JOB SITE ��S -e �-,a-' c�- �f'c- � � � • <br /> � �_ <br /> � c� <br /> Owner's Name j e v �j � r'►.c,� 7�-- Telephone Number ���— l S/5 <br /> Mailing Address �� �� I� �,r� ��.� �✓-� , � <br /> Sprinkler Contractor's Name v�� S e��i« ��_ TelephoneNumber ���l U�-�� <br /> Contact Person lU '� Lc�� G <br /> Mailing Address v c� c�z- � ✓�'��- 5—,�� � <br /> `VATER SUPPLY <br /> Lake Well� City <br /> BACKFLOW DT'"�^�' _ <br /> AVB <br /> 1� S��CT-1 v��t S / , <br /> Sprinklers l (����-`� <br /> - t��� - S% � <br /> lNs�e��� w <br /> � ���� <br /> — �� �� �s �; <br /> �n�uLlc l� �7 <br /> /�d��`fi`�l ��n��� �i �a�� �-�d <br /> � /`�re���� <br /> PERMIT FEE CALCULA 1 iv�. <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) $ 35. 50 <br /> The undersi�ned hereby applies to the City for issuance of a Sprinkler System Pernut, 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 applicatio re complete, true and correct. <br /> ;" <br /> Applicant Date <br /> *********************** ******************************************************* <br /> Approved pproved with Corrections Denied <br /> Reviewed by: � �„ / <br /> %uw Date 5'l5—U� <br />