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, i <br /> Please check one: New /� Addition <br /> JOB STTE Z / <br /> �� <br /> Owner's Name Telephone Number - <br /> Ma�ing Address <br /> SprinklerContractor'sNam elephenelV�,�^:ber �f��//�f� <br /> Contact Person <br /> Mailing Address � � • � <br /> `VATER SUPPLY � �i� ..S�S Y� <br /> Lake tiVell� City <br /> BACKFLO`V DEVICE � <br /> AVB P VB � ���/• --- <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers <br /> TOTAL <br /> HYDRAULIC CALCITLATIONS Desia Data: <br /> Area of Application: Sq. Ft. <br /> Covera�e per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: <br /> Total Water Required: Gp� <br /> PER�'�IIT FEE CALCULATION <br /> 1. Permit Fee $ 3 5.00 <br /> 2. State Surchar�e $ .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. TOTAL PERitiIIT FEE (Add lines 1-3 above) $ , <br /> The undersi�ned 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 Date ��� �O C� <br /> *****�******�****�*******�*************��********�**********�******************** <br /> � , <br /> Approved �'( Approved with Corrections Denieti <br /> Revie«ed by: -� � <br /> �;��� � �:r � . Date � � � <br />