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Please check one: New cT' 'on <br /> JOB SITE <br /> ` ( y � L � <br /> Owner's Name �� _ ld-� �.f o �� �j�f ��Ft'�elephone Number_ � �� � �j��� <br /> � -- <br /> Mailing Address � � �� � , ��� ,���-�_ ��' <br /> Sprinkler Contractor's Name�c- ���'ti. t- (-j,�¢�, Telephone Number <br /> Contact Person <br /> Mailing Address � <br /> `VAT'ER SUPPLY <br /> Lake Well ��"�� City <br /> BACKFLOW DEVICE <br /> AVB P VB <br /> Year of <br /> � <br /> Make Model Manufacture uanti <br /> Sprinklers C�,�,.� � L�� <br /> TOTAL <br /> HYDRAiTI,IC CALCULATIONS Design Data: <br /> Area of Application: � �_,z� Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: )`� -- �� <br /> Total Water Required: / D��z� F=(',,�Jr GPM <br /> PERII�IIT 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) $ ;5 , S� <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 o x-�i�pplicat' n are complete, true and correct. <br /> � <br /> Applicant -� �� Date�-f' Z �C� <br /> ***********�****** **** ******************************�************************* <br /> Approved � Approved with Corrections Denied <br /> Reviewed by: � <br /> �'"� Date (�— jZ- oo <br />