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Please check one: New � Addition <br /> JOB SITE <br /> Owner's Name R�a�,� �o�/��, Telephone Number ✓r' �.� - d c�/� <br /> Mailing Address ��,�5'" ,J�L U/� L-ff N C (�f'�/f/D <br /> Sprinkler Contractor's Name (��CE,oIi�L-C�'t/�c. �•�'�� Telephone Number .��� -o �,/3� <br /> Contact Person G��q/N �i�ia.v� <br /> Mailing Address ,/�, �� ,��/��(} �v D /`f1'�!4 .U'� <br /> WATER SUPPLY � <br /> Lake Well l�� City <br /> BACKFLOW DEVICE <br /> AVB PVB � RPZ <br /> Year of <br /> Make Model Manufacture uantit <br /> S rinklers � - � � <br /> /���/L'f�if'� ��-�� vr�oo — <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: L.f} (,�},V Sq. Ft. <br /> Coverage per Sprinkler: !�5 /�'t�u�R r� Sq. Ft. <br /> No. of Sprinklers: S r i R Ea <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 /> Applicant T ""' <br /> � ..�,� Date J�' -� 3� � ° <br /> **�*****�***********�****�*�*****************�**��**�****�x�**�*�************** <br /> Approved Approved with Corrections Denied <br /> Reviewed by: �� <br /> � <br /> �� � Date S�,��; -g�c <br /> ` � � ��� � � ��s ►���y�:;!:c'1J (z�v `�-' �r4C f c F l v c�i �E �.`i CL � <br /> � {}v1 !4-�;lc�c On�� r � <br />