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� R <br /> Please check one: New �. Addition <br /> JOB SITE � �Q ( ��.�`1��c_,i t., G-c�- � �� , <br /> Owner's Name��r,a.,-�,�v� �,�-��C�� Telephone Number_ ��� y 7� (�-{/�� <br /> Mailing Address_ � I 0 i �E r;�l c��-I c: rc� �� � U�d�• � <br /> SprinkterContractor'sName I �c�( �� -�; ;,J�.,11. TelephoneNumber � �G�j 4�� � 'iZ.� <br /> Contact Person �c� e.. t e,�a�,�,� <br /> Mailing Address_ S 1 1 � �d�.��5�� �i U-- l `:-} . �,�U,;� � ��, ��1�� ,1� �'<'�� . <br /> t ,�� rJ 5 ..�� <br /> �VATER SUPPLY <br /> La.ke 1L R'ell City <br /> BACKFLO`V DEVICE <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers � �'��'S � u,n��-E:.� l- <� � 3 � <br /> `- S U��-t, ! ��C1 - S (< C� �'' 'L <br /> - TOTAL ��'� <br /> � T— <br /> HYDRAULTC CALCULATIONS Design Data: <br /> Area of Application: Sd� Sq. Ft. <br /> Coverage per Sprinkler: {�+�< ,��o � -.�� (;,� Sq. Ft. <br /> No. of Sprinklers: " <br /> Total Water Required: �J Gp� <br /> PERMIT FEE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> 2. State SurcharQe $ .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. TOTAL PERIVIIT FEE (Add lines 1-3 above) $ 3� : r�� <br /> The undersi�ned 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 correct. <br /> , <br /> i � � <br /> Applicant ,�:,�.�- �—� Date �� ?�`�oJ <br /> ***********************************************************�**********�********** <br /> Approved_'�� Approved with Corrections Denied <br /> Reviewed by: <br /> ;'�,,^ c.�-�, �t,�-r-a--� Date � �� __0� <br /> � pv��;fi C�\\ �0� .�SP���. �� ���rcr cc�MP\c�;u ^ <br />