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�� �► �.������7 <br /> Please check one: New '� Addition - <br /> JOB SITE �S �� `( ,,,,�,f �(cr <br /> Owner's Name ��--{�,� ,.� ;s L�2 �(s Telephone Number �7 I - �l� o <br /> Mailing Address 3 5 3 5 �,�,� �,a c:e_ <br /> Sprinkler Contractor's Name ,�-��e�-��-�,��,,, Telephone Number.�JlQ�` 2�5�0 <br /> Contact Person �-{c�r-,�. �e.I c�,c o�-� _ <br /> Mailing Address �j2�b V r � t �J�5�2� <br /> WATER SUPPLY ' / <br /> Lake Well City v� <br /> BACKFLOW DEVICE <br /> AVB PVB � RPZ <br /> Year of <br /> Make Model Manufacture uantit <br /> S rinklers � � � <br /> r Z <br /> TO'TAL �-, <br /> HYDRAULIC CALCULATIONS Design ata: <br /> Area of Application: �� : Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: J�3 <br /> Total Water Required: iC7- t 2 �P� GPM <br /> PERMIT FEE CALCULATION <br /> l. 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 conect. <br /> Applicant <br /> � � �!� Date �� �� � <br /> ******************* ****�***********�**x���*******��***�**�****x�**********�**** <br /> � <br /> Approved Approved.with Conections Denied <br /> Reviewed by• " <br /> Date �� 9 <br />