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� /�. "�1 �,i� i <br /> Please check one: New � Addition <br /> �, <br /> JOB STTE �/ �j``.�.�. '�i,����� .�'l!.� ,% 1�< i �� <br /> Owner's Name / �� - � r ' ` �� - Telephone Number �'f/�- -<;'�r��!- <br /> � <br /> Mailing Address i'/ � '�'%" �"� <br /> � <br /> Sprinkler Contractor's Name��Z�k: � � '�,� � � ��i�lephone Number .��,/� -C�j;l� <br /> Contact Person ���� �T r � � , , , , t'> � 1 <br /> Mailing Address /� =-�.�,'��� ��,�c � � � < <� �c`��i LJ�;� � �� � ��</ <br /> WATER SUPPLY � <br /> Lake Well � City <br /> BACKFLOW DEVICE <br /> AVB PVB � RPZ <br /> Year of <br /> Make Model Manufacture uantit <br /> _ , � � <br /> S rinklers ����- � �`� <br /> .%�c�� ,.�� � �r�/ t ���'� <br /> TOTAL <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 <br /> PERMIT FEE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> 2. State Surcharge. $ .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 <br /> to do all work in strict accordance with the ordinances of the City and State regulations, and <br /> certifies that all statements made on this application are complete, true and correct. <br /> Applicant ;'�_.L'�..-- ��.z, , ti..., _ Date � `' � - y� <br /> �***************** *****�*******�******���*x��************�********�**x�**�****� <br /> Approved Approved with Corrections Denied <br /> Reviewed by' �j <br /> � � / l <br /> �1,�- ,,�.-_- Date � �` <br />