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t <br /> Please check one: New x Addition <br /> w <br /> JOB STI'E O /�,�.,.,� <br /> Owner's Name G��+-��.. le one Number �S.Z'Y7Z�,�/l7 <br /> w <br /> Mailing Address �,..-•_.�' <br /> Sprinkler Contractor's N e TelephoneNumber �,s �2�9f////� <br /> .�--- <br /> Contact Person . <br /> Mailing Address ��o � � � <br /> WATER SUPPLY <br /> Lake Well � City <br /> BACKFLOW DEVICE <br /> AVB � PVB <br /> Year of <br /> � Mo el Manufacture uant� <br /> Sprinklers ' <br /> TOTAL <br /> FIYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: �dl�d Sq. Ft. <br /> Coverage per Sprinkler: �p Sq. Ft. <br /> No. of Sprinklers: <br /> Total Water Required: . GPM <br /> PERMIT 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 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 /> � <br /> Applicant � Date,S ��� QZ <br /> ********************************************************************************* <br /> Approved �� Approved with Corrections Denied <br /> Reviewed by: <br /> �``ct�� �`�wvw.� Date 5�2`i-o:i. <br /> �- M�k� SU��Z �-t;, r�o, � :5 ��b SeSt`.` �,�cz,, <br />