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�a..� �� �9 <br /> Please check one: N t� � ��r� �'t � u G-�L d�` <br /> ew � Addrtion � <br /> JOB SITE �Z.� � � � � � � �, 1�-�/�'__ <br /> Owner's Name 1 +���{` � � ��'�-'� TelephoneNumber <br /> Ma�in Address �=�- <br /> � �i��-� •r�_ <br /> Sprinkler Contractor's Name �;.1.; rc w��� �r, Tele honeNumber �%:�Z - `- ' <br /> P l 7 2 _ �'�=�'��� <br /> , .�,.���.,,�k„_j �•�;�� `�`�_ y G 3� <br /> Contact Person _`��,�,�, �. �,�; ���c:�� <br /> Mailing Address ��i s�i �'����.� t.�,� �C'� �t7`' vL� , /`-( t�l ��..'-.��/� � <br /> �VATER SUPPL y� <br /> Lake Well City /� <br /> BACKFLO`V DEVICE � <br /> AVB P VB <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers `���,�, ,n� ;: � <br /> Sc��i � 1�>r- ��<-. �ci <br /> s�b c�a ����-y �..vv �z= <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 $ 1.50 <br /> 4. TOTAL PERII�IIT FEE (Add lines 1-3 above) $ 3 �, � �, <br /> The undersijned hereby applies to the City for issuance of a Sprinkler System Pernut, 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 k �-� � `�� ' Date � _� <br /> � —�' <br /> ********************�*******************�**************************************** <br /> Approved � Approved with Corrections Denied <br /> Reviewed by: � / <br /> �iie� t_� / <br /> Date�-Zl-� <br />