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Please check one: New�_ Addition <br /> JOB SITE�t;��,�ti,� /16f l nr; <br /> Owner's Name S�. �;�- .�' �' � �l�/ �� Telephone Number <br /> Mailing Address a c�� �e� �= /� !�-t�/C u.r G. i�-N�— <br /> Sprinkler Contractor's Name _ f�/t�/.� C�4 Telephone Numbe �-� �' 7' � <br /> Contact Person L. u �i= C��� 3��� ?�!s� <br /> Mailing Address � 7 �� / �'�� � ,41v�L � d w a C� /�� w j��; � j�5 3 � 7 � <br /> �VATER SUPPLY <br /> Lake Well_� City <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers � r��tL'� �i�r�c' ,� �' p�2 PG 1+-�!S'' <br /> TOTAL <br /> HYDRAULIC CALCITI.ATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: <br /> Total Water Required: Gp� <br /> PER.i1�IIT FEE CALCULATION <br /> 1. Pernut 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 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 application are complete, true and conect. <br /> Applicant .�" -z. Date G � <br /> � <br /> ******************************************************�****** ********�********** <br /> ,r <br /> Approved Approved with Corrections Denied <br /> Reviewed by: ' � <br /> -�t� Date H-1 q-�� <br />