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ti � �abo <br /> � <br /> Please check one: New_� Addition <br /> Jos SrrE 2� 5 S K�,��� ��� . <br /> Owner's Name_ �Q--� ��qs��� TelephoneNumber�: �'- t` � ^ � <br /> ,�l 1 �7;�_1 �-- <br /> Mailing Address o2(2��5 k��\u �J� , O�c�� <br /> Sprinkler Contractor's Name ��ccer`Sa�- Cc�,Swe.�,� TelephoneNumber �`I� 3 l2-� <br /> Contact Person � c�e l�1 e,���CY� - <br /> Mailing Address S( l S �(��S�t�-��1 S� . W�D1 L 1�1�; n �n cJ � <br /> `VAT'ER SUPPLY <br /> Lake �-- Well City <br /> BACKFLOW DEVICE <br /> AVB PVB �� <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers _ _ -��U t�T�.'(L P�P �j 9 �� <br /> TOTAL � � <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: ,=t) ���,r� Sq. Ft. <br /> Coverage per Sprinkler: ,� �/i�� Sq. Ft. <br /> No. of Sprinklers: �� <br /> Total Water Required: a..p GPM <br /> PERIVIIT FEE CALCULATION <br /> 1. Pernut Fee $ 3 5.00 <br /> 2. State Surchar�e $ .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. TOTAL PERi�IIT FEE (Add lines 1-3 above) $ 3 5., sb <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 Ct,�,.e Date � /7 9� <br /> *****************�****** **********�***********�x********************************* <br /> Approved pproved with Corrections Denied <br /> Reviewed by: . <br /> .��� Date_ q—/ 7—�'`�' <br />