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` 0 r <br /> /b3" <br /> b <br /> • <br /> Please check one: New 1/-----Addition • <br /> JOB SITE - <br /> Owner's Name % _ J c—r". Telephone Number <br /> ,1d aiec4 <br /> Mailing Address e. ,, r <br /> 1 <br /> Sprinkler Contractor's Name ��ma y, -,,,y( c c- r,i .Telephone Number 9? ? <br /> Contact Person Jerry 7`„7!,c_ <br /> Mailing Address � la S �yf,� ;, �,c /Y2.4�� <br /> WATER SUPPLY <br /> Lake Well ✓ City <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture Ouantity <br /> Sprinklers Ny.., .- PG P 9 k l/ <br /> g :.�;,-o.c /fro v /4' <br /> /vv <br /> TOTAL ,s"--- <br /> iYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: S P/i, /oc, • so J r' <br /> Total Water Required: SCS 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 PP Date ‘r-./ r <br /> ********** *****.********** * ****************************************** <br /> Approved Approved with Corrections Denied <br /> Reviewed by: <br /> /eAre Date ,'�— <br />