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- <br /> _ . � <br /> Please check one: New � ! Addition <br /> � <br /> JOB SITE -��6Z C� �1J �1 L i v 6- � <br /> Owner's Name�'-a,M E Telephone Number <br /> Mailing Address //SS �,I�R r��T,4��- LIU • ��' ��_,4�-p. <br /> Sprinkler Contractor's Name -�U/J S�ZI�,����(Z Telephone Number(o f Z-�3�[ _7��,SC <br /> Contact Person �� �Zy ���-� <br /> Mailing Address JIaL� /!e 9 � �T� /v� ^�.4 t�v! �- c� l�cv � . <br /> `VATER SUPPLY <br /> Lake Well_� City <br /> BACKFLO`V DEVICE <br /> AVB PVB � <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers �u;v t�� `�C> >.7. �8 =�`j' �� <br /> �P�2�'��zo�_ Sp2l-�v <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: Gp� <br /> PERIVIIT FEE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> 2. State Surchar�e $ .50 <br /> 3. Mail-In Fee $ �g- <br /> 4. TOTAL PERMIT FEE (Add lines 1-3 above) $ 3 S. 5� <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. <br /> Applicant �� Date <br /> ************** ** *************************************************************** <br /> Approved Approved with Corrections Denied <br /> Reviewed by: ' <br /> Date — <br />