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Please check one: New Addition >( <br /> JOB SITE 150 Clr'c1-P 0 O tee/W/20 'Ro S'a G, t k <br /> Owner's Name <p,, C,\ [�e.� p TelephoneLl <br /> Number �— <br /> � n v� `v1e;�✓��1 <br /> Making Address y : ; r c.c <br /> Sprinkler Contractor's Name Mo,ders-,/-00-15 <br /> Telephone Number Gj 3 3 - 3 3'3 9 <br /> Contact Person `Se\Ltd.c i,-\ <br /> Mailing Address <br /> WATER SUPPLY <br /> Lake Well City <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> Make d Model Manufacture Quantity <br /> Sprinklers CrP <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: - -- Sq. Ft. <br /> Coverage per Sprinkler: i _reak Sq. Ft. <br /> No. of Sprinklers: (nom <br /> Total Water Required: 16 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 _)Af Date <br /> ********************************************************************************** <br /> Approved X Approved with Corrections Denied <br /> Reviewed by: /`' <br /> Date 6-z 0 -OD <br />