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, <br /> � <br /> Please check one: New Addition <br /> JOB STTE �� �� ��'%� � �,��{S �` �- L- � '�Y � � � <br /> Owner's Name _`�,c�� -f-� d �A ��'�J�{ Telephone Number � C�i y� <br /> / <br /> Mailing Address <br /> Sprinkler Contractor's Name �T � � Telephone Number ��'i <br /> Contact Person �. (y ��� � � �`l L`� _ <br /> Mailing Address � 7 Q� �/� �j � �. ��� /c:. C� ��� �G�' /�l 1� S S 3 �f � <br /> WATER SUPPLY � <br /> Lake Well � Ciry <br /> BACKFLOW DEVICE <br /> AVB PVB � RPZ <br /> Year of <br /> Make Model Manufacture uanti <br /> S rinklers , - <br /> � <br /> --i��� G .��-� �-�r���-���--�� � C f"9 �� %- /�� <br /> TO'I'AL <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 $ 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 undersigned hereby applies to the City for issuance of a Sprinkler System Permit, agrees <br /> to do all work in strict accordance with the ordinances of the City and State regulations, and <br /> certifies that all statements made on this application are complete, true and correct. <br /> � <br /> Applicant �--�� --�-�_=—� Date l� �'6 <br /> ***********�**********�*********x�x�***�**�*�**��*���**�****�**x��*****�********* <br /> Approved Approved with Corrections Denied <br /> Reviewed by <br /> �.� J'�� Date � � <br />