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Please check one: New d Addition <br /> JOB SITE <br /> Owner's Name Telephone Number <br /> Mailing Address lo? &S C C o v,a co, ks <br /> Sprinkler Contractor's Name A 4\cy y, 5 �r t�,�a �,'o Telephone Number 9c/3 <br /> Contact Person V' Y.csZ 0-lo, ork- <br /> Mailing Address t-30 t Caw,b r c1 g.Q. 5+. 440'Q <br /> WATER SUPPLY <br /> Lake Well City <br /> )3ACKFLOW DEVICE <br /> AVB PVB X <br /> Year of <br /> Make Model Manufacture Ouantity <br /> Sprinklers <br /> w. o fiC we sek&o s <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 CALCULATIQN <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 /> sir/ <br /> Applicant /, ' .lc C Date <br /> ************************************************* **************************** <br /> Approved Approved with Corrections Denied <br /> Reviewed by, / <br /> i.r � � Date 9� <br />