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. <br /> Please check one: New �� Addition � <br /> JOB SITE 1� t i�� �+ 2a`�L CL� �l k�1—U - <br /> Owner's Name �' � • �' Telephone Number <br /> Mailing Address ;�,L�1 N G f��H ��n-.tit lZ-�%-� D <br /> Sprinkler Contractor's Name >4��- /-1 �.i'% �= Telephone Number `��l�-��� �� <br /> Contact Person �� <� �� �� , 1--�LIJS �" l'L <br /> S <br /> Mailing Address C� S C 1 C i 7 Y ls'� S 7 1'K-w�' � , � . 5 3 N �/ <br /> WATER SUPPLY ' <br /> Lake Well �_ City <br /> BACKFLOW DEVICE <br /> AVB PVB �_ RPZ <br /> Year of <br /> Make Model Manufacture Quantitv <br /> �rinklers �y� � �, � <br /> }-k-�: T�=- R.. G k-�1 1� <br /> �` . 1 v <br /> -Iv n� �Tf�IZ S P G�-!� <br /> TOTAL �-t C� � <br />( IC CALCULATIONS Design Data: <br /> HYDRAUL Sq. Ft. <br /> Area of Application: sq. Ft. <br /> Coverage per Sprinkler: <br /> No. of Sprinklers: �� GPM <br /> Total Water Required: <br /> pERMIT FEE CALCULATION $ 35.00 <br /> 1, permit Fee $ .50 <br /> 2. State Surchara�e. $ 1.50 <br /> 3, Mail-In Fee <br /> $ ____— <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 <br /> to do all work in strict accordance with the ordinances of the City and State regulations, and <br /> ' certifies that all statements made on this application are complete, true and correct. <br /> � <br /> � �/ ,,�. , ^ Date L/�23��.� <br /> � C'. �C <br /> Applicant ,_, <br /> ****�***************�***�*****�******************x��**�*�**********�********�** <br /> Approved <br /> Approved with Conections Denied <br /> Reviewed by: <br /> Date <br />