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Please check one: New Addition (. <br /> JOB SITE /-/.o 7 Tr, <br /> Owner's Name % /1/4' N; Telephone Number <br /> Mailing Address SL?S7- o 1'c n) o a r c A n rN[) r <br /> Sprinkler Contractor's Name ,j 1'u Cr— Go tTelephoneNumber �,S`d2 /��, O t SC 3 <br /> Contact Person l r e c <br /> Mailing Address ./ ( ' n') k&1°--rr' /o 3 ✓e-. � JX4'( ct /70 SS-3 7-7 <br /> WATER SUPPLY / <br /> Lake Well V City <br /> BACKFLOW DEVICE • <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture Quantity <br /> Sprinklers 6,J o - 60 a o a o o �% <br /> ci; /11/,£• V-00 a oo y <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 // '� j Date 7 3 "T,\) <br /> ********************************************************************************* <br /> Approved Approved with Corrections Denied <br /> Reviewed by: G)N\clocc. p3.b..)ctori <br /> Date }7-3 --01 <br />