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Please check one: New '� Addition <br /> JOB SITE <br /> Owner's Name i� i✓ f/ �/ ,-z-�) Telephone Number � Z-- 7G 2 z <br /> Mailing Address OA< Si <br /> Sprinkler Contractor's Name TelephoneNumber <br /> Contact Person <br /> Mailing Address <br /> WATER SUPPLY <br /> Lake Well ✓ City <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture QuantLty <br /> Sprinklers / tire ,u8,�o <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 Surcharge $ .50 <br /> 3. Mail-In Fee $ . ,. <br /> 4. TOTAL.PERiNI M FEE (Add lines 1-3 above) $ _ 5 5 <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 2 /7 Zo oG <br /> Approved / Approved with Corrections Denied <br /> Reviewed by: <br /> �� Date 7-17-Da <br />