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� � <br /> , <br /> Please check one: New i Addition <br /> JOB STTE � (o � / c���.C r'�+� D��l (—( l L c � <br /> Owner's Name � �7'� ����� � ��;� Telephone Number__T7���c� <br /> Mailing Address . <br /> Sprinkler Contractor's Name�1`—'�� C� Telephonel�Tumber ` vP' <br /> Contact Person �/ � l= <br /> t <br /> Mailin?Address�� g'�O �/ �h�/��� J/� C D /�l l ,g,_TS 3 � 7 <br /> �VATER SUPPLY <br /> Lake Well_� City <br /> BACKFLO`V DEVICE - <br /> AVB P VB <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers ,L/��� � �,p p y � <br /> � T�1T�.j, � �!,� <br /> HYDRAULIC CALCULATIONS Desio Data: <br /> Area of Application: Sq. Ft. <br /> Covera�e per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: <br /> Total Water Required: Gp� <br /> PERII�IIT 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 PERiI�IIT FEE (Add lines 1-3 above) $ " " , - <br /> The undersi�ned hereby applies to the City for issuance of a Sprinkler System Pemut, a�rees to do <br /> all�vork 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 / v jJ 1' �D/�✓l,E Date ��/�� � <br /> ****�*******�*****************�**********�*******�*****�******�***�************** <br /> i <br /> Approved ' Approved with Corrections Denieri <br /> , <br /> Revie�ved by: <br /> Date ' <br />