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t 35 50 <br /> 'V <br /> Please check one: New Addition Limited Energy Technology <br /> Systems License # <br /> JOB SITE �Z4 9(p CAS 6eoj, <br /> Owner's Name C Telephone Number qj-j -q'71 <br /> Mailing Address JP aQ <br /> Sprinkler Contractor's Name '1,p ('� �!(W/7 � �� eNumber 9� <br /> Contact Person , <br /> Mailing Address�3�196 J��%aj�q/ <br /> WATER SUPPLY <br /> Lake V Well City <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> PD Make Model Manufacture Quantit <br /> Sprinklers `l�i j n ��r F--rLlZ�Fr <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 $ 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 /> Applicant Date C"J <br /> Approved ,'�"� pro ed with Corrections Denied <br /> Reviewed Date <br /> BY: t�' -6 y <br /> Z�S� �C.Tce11 n�C�r� ��frtr �C�PIe�-.�'� <br />