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� <br /> Please check one: New �� Addition <br /> Jos srrE L� '3 �� � J�� r �-�, � ��r� c�r <br /> Owner's Name�a c�r C 1� �,L r�;���,,���=L� Telephone Number � `1 �Z l �`l �'1 <br /> Mailing Address � ��, �,.,` <br /> Spri.nkler Contractor's Name_�r��.��rv,,,ti,,t���, ,� Te ep oneNumber ��Z `� I�''�i <br /> 1 l�L�..+� �C'�.� L�.l � <br /> Contact Person ����,�� � j � C�� <br /> MailinQ Address .`�% ��1 (����'•�� �,L � �Z "1 � J � . <br /> o c ��`:t'� � ��.�3�P L� <br /> �yATER SUPPL <br /> Lake `Vell City <br /> BACKFLO`V DEVICE � <br /> AVB P VB <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers IZ�,�k �?�c� 3�z���� ��� <br /> �?�_5�. '',C � I �z.% 3Y� <br /> TOTAL ,�fD <br /> HYDRAULIC CALCITLATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Covera�e per Sprin]der: Sq. Ft. <br /> No. of Sprinklers: <br /> Total Water Required: Gp� <br /> PER.�I�IIT FEE CALCULATION <br /> 1. Pernut Fee $ 3 5.00 <br /> Z. State Surcharee $ .50 <br /> 3. Mail-In Fee <br /> 4. TOTAL PER���IIT FEE ��dd lines 1-3 above ��p�� ��n�� t* $ � 1.50 � <br /> . ( ) � $ .37� o� <br /> The undersi�ned hereby applies to �the City for issuance of a Sprinkler System Permit, a�rees to do <br /> all�vork in strict accordance with the ordinances of the City and State regulations, and certifies that <br /> all statements made on this applica�tion are complete, true and correct. <br /> � <br /> � �JApplicant ` ��� � Date /C — � � � <br /> **********�*�***************�:*�****�****�*****************************�********** <br /> Approved � Approved with Corrections Denied <br /> Reviewed by: <br /> i <br /> J <br /> �,J . �Ut'_.� Date_I p_��-(?-�; <br />