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Please check one: New� Addition <br /> JOB STTE '3 O�� Wo�.-t-�- 5��� �?� �'r��p Nl N .S`�S ��� <br /> Owner's Name �Q TelephoneNumber �'-�--y7/-�.��� <br /> Mailing Address � W�1� �� <br /> Sprinkler Contractor's Name ���rg;��.� cR,��,�'elephone Number����- � <br /> Contact Person �� L�S � ��,��� <br /> Mailing Address ��'�[� �fUl���.����:A ��11c_���._�`'�'�� �l� ��Q� <br /> WATER SUPPLY <br /> Lake_� Well City <br /> BACKFLOW DEVICE <br /> - AVB PVB <br /> Year of <br /> Make Model Manufacture uantit <br /> Sprinklers r�_ � `�� �'Z <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. 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) $ 35-S C� <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 com lete, true and conect. <br /> Applicant �'�" � Date�^�-� <br /> ******* ********************************************************************** <br /> Approved Approved with Corrections Denied <br /> Reviewed by: G�0.,� Date 6- 5—d� <br />