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j - - Q�a�� � <br /> Please check one: New ✓ Addition <br /> JOB STTE s� � �� `a�4 �..k c �J�v� ��no <br /> -T <br /> Owner's Name �r►�, C,�6. � �C Telephone Number �/�3 - �a2 9� <br /> Mailing Address ,�,s�.s— �,oti� 1,.._k� ,/-ot') �.•./, , o+.,a /�k� t7/In �t� f'�. <br /> Sprinkler Contractor's Name �.-,�r��-�• ( �r�,��Telephone Number y� � - a�'�S <br /> Contact Person ��,•, /�,'•-`,u <br /> Mailing Address �e� i ���.:, ,S� �nl c /�l.�...i•. f_S�js 5 � <br /> `VATER SUPPLY <br /> Lake � Well City <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture uantit <br /> Sprinklers �-..�,. f�C�/� �ooc� /e2 <br /> , ,,..: �.n. /�o v d2 oo�c /v <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: GPM <br /> PERMIT 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 PERMIT FEE (Add lines 1-3 above) $ <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 Date ,��-pv <br /> ********** * *** ******* * ** ************************************************** <br /> Approved ,/ ' Ap oved with Corrections Denied <br /> c <br /> Reviewed by: ' <br /> ��� Date 5—�(7 `- OC� <br />