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<br /> Please check one: New� Addition
<br /> JOB SITE ��'�C_" f c=•x S �;
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<br /> Owner's Name /��,,,� � � �'1/1...� �j,I l--._ Telephone Number
<br /> Mailing Address /:4::,�.�' ,��x � �. �� ,-„ ,. r � I')'Jr i_
<br /> Sprinkler Contractor's Name ���... �� r�. ( � '��>,��.;��-TelephoneNumber l i,� .�j�y -�� S�-�.�""
<br /> Contact Person ,� r,,,� �,' '�T.,., � ,�?/� � �Z yl c� ��'� ir �
<br /> Mailing Address �'',���}. .; " ,r��,;.-, �.S�. �l"�,� �c ,�'� �. '
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<br /> `VATER SUPPLY
<br /> Lake Well !/" City
<br /> BACKFLOW DEVICE
<br /> AVB PVB 4.�---
<br /> Year of
<br /> Make Model Manufacture uantit
<br /> Sprinklers ,�<,,;,h:,.�.�' �-�l�� U c� �,
<br /> ,� /�ro o r��f y�:
<br /> ��.-, 14-r �G/-� r, �, l C-,-
<br /> TOTE�. '�i �_.
<br /> HYDRAULIC CALCULATIONS Design Data:
<br /> Area of Application: Sq. Ft.
<br /> Coverage per Sprinkler: Sq. Ft.
<br /> No. of Sprinklers: ,. �,,,,
<br /> Total Water Required: `�5��- GPM j:_k-,- �s ��. ,
<br /> ,
<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) $ 3 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 on this application are complete, true and correct.
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<br /> Applicant ,— ' -.-,�//�_ Date �-- ,��-cr�v
<br /> **************�* *�** ********** **�*****************************�*************
<br /> �.
<br /> Approved Approved with Corrections Denied
<br /> Reviewed by: � Date 7 /� -�(7
<br /> � /�ctd i�►\on a� P8k tM,� �P�u r✓�tc� �'2 U�4-C'k F'/o c,J �0 l'P✓'P rt� �
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