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Please check one: New � Addition <br /> JOB srrE 1 v s� � �w, �, 1�ra�, ►�we <br /> Owner's Name ��,�� '� Y �� r Z Telephone Number <br /> Mailing Address S c,v� <br /> Sprinkler Contractor's Name �t�t��- I��� , Telephone Number �1� Z -9'c�r-���� <br /> Contact Person \�� �� � <br /> Mailing Address �S 6 1 C , `�•� vr-t s�F ('��k w 4�/ � �-c r. �� �,v i-� �S 3 z>y <br /> WATER SUPPLY <br /> Lake�_ Well City <br /> BACKFLOW DEVICE <br /> - AVB PVB <br /> Year of <br /> Make Model Manufacture uantit <br /> Sprinklers �1��-w �9 {� U�( � <br /> � L�o S �C� d Lj c�� <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: � r''� a � GPM (�ti� ��...�� <br /> PERMIT 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) $ `�� , cL <br /> The undersigned 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 conect. <br /> A licant ����'`�� � Date � � <br /> PP / / G� <br /> ********************************************************************************* <br /> Approved � Approved with Conections Denied <br /> Reviewed by: �,S �� <br /> �� Date <br />. �,/e e� ;,�5 �c.1-.�� .r.,t: � c c n�\c �—c cJ � <br /> � B <br />