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d <br /> Please check one: New )( Addition <br /> JOB SITE g �(� �.� C 1�'f}L 0,471 <br /> Owner's Name Al. Telephone Number <br /> Mailing Address c20..`vt f cc • <br /> Sprinkler Contractor's Name AI u L P • Telephone Number f//-//34?j <br /> Contact Person Th,flu <br /> Mailing Address 647 S/ w s.A.„„4 P.A <br /> WATER SUPPLY <br /> Lake Well City )C <br /> $ACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> ake Model Ma facture Ountity <br /> • <br /> (off.• 5702_ ToR•ri• /Z. <br /> TOTAL <br /> JIYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: /00 v - Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: <br /> Total Water Required: b( 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 <br /> do all work in strict accordance with the ordinances of the City and State regulations, and certifies <br /> that all statements made on this application are complete, true and correct. <br /> Applicant i Date 7• Z 9 t <br /> ******** ********************************************************************* <br /> Approved Approved with Corrections Denied <br /> Reviewed by: / <br /> J/4' ��al_i Date /��� <br />