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r r � <br /> ,' <br /> Please check one: New � Addition . <br /> JOB SITE �Z_5 Z S � � �� �..� �,��,,� = <br /> Owner's Name k �,ti, 1�� ��,,�h� � Telephone Number ��1—7lp�Ci <br /> MailingAddress 'ZS�' L5- 1� ii�, .�;,.,� <br /> Sprinkler Contractor's Name �u,,,,.�„� � j,,,,.,���,�,�'�ephone Number �'Z L —� 3� cr <br /> Contact Person ��4,�', � '�y C�c�_� <br /> Mailing Address S�> 4�`�'t C--'���rs�,..��- ��-1 �,(�� ��� �'� <br /> WATER SUPPLY s�s 3<<�� <br /> Lake _� Well City <br /> �ACKFLOW DEVICE - <br /> AVB PVB <br /> Year of <br /> _ Make Model Manufacture Ouantitv <br /> Snrinklers � �k �i ,�Z 4T-' �i� 12� I�v r �'2�- � <br /> ��c3� ��r S <br /> TOTAL <br /> HI'DRAULIC CALCULATION Design Data: . <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. . <br /> No. of Sprinklers: <br /> Total Water Required: GPM <br /> PER�VIIT FEE CALCULATION <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 Ciry for issuance of a Sprinkler System Permit, agrees to <br /> do all work in strict accordance with the ordinances of the City and State regulations, and certifies <br /> that all statements made on this application are complete, true and correct. <br /> . �� � <br /> Applicant _ `� `Y' Date ^7���' � ' <br /> �k����X��k��k����ca;e�exa;c3c3c�jc�;e$c�ex$e�c�k�e�e3e3��X�C�e�C�CX$e�c>c�er'c$exxa'c$cs;c�c$a�e�jc3cacaca;c�c�;c�?c�e3cie�ca,Y;e3,c3,e�c�c�ex3,c�e$ex�e <br /> Approved � Approved with Corrections Denied <br /> Reviewed by: <br /> ,�� ���-� -- . <br /> Date _ � �9� <br />