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�� ,`� � � <br /> Please check one: New � Addition <br /> JOB STTE ' � � <br /> Owner's Name � � Telephone Number _ �- �1 <br /> Mailing Address �c.�,�v�(Z� <br /> � n <br /> Sprinkler Contractor's Name f Ip �, �.�t'`,�C�_Telephone Number ' �Z- �[� <br /> Contact Person <br /> Mailing Address L�7� 1 t`��� S�'� W�-��'1 �3� <br /> WATER SUPP ' <br /> Lake Well City <br /> BACKFLOW DEVICE �,p ''r-�(� <br /> AVB PVB RpZ ,.�Dn�? ��`� <br /> Year of <br /> Make Model Manufacture Quantitv <br /> �rinklers ��'� �-�1�� �� <br /> �� <br /> TOTAL o'Z� <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: GPM <br /> PERMIT FEE CALCLTLATION <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) $ <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 Date �`��- ��� <br /> *****�*��****** *************�***�*��x�*�**�***�*x�����**���*�x�**�***�****�*�x�* <br /> , <br /> Approved Approved with C�rrections Denied <br /> Reviewed b : <br /> � Date �'�� <br />