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� l <br /> Please check one: New Addition �/ ' <br /> JOB STTE � � �'- �Yl� �( � S <br /> Owner's Name � <br /> �CC�Q?-(.� ct C� Telephone Number� �`_�—�{�7�--�S'cg00 <br /> Ma�ing Address_�, �. �Q. �-- ��1 � � � �c,�S � <br /> Sprinkler Coa�tractor's Name c�.p S � elephone Number�� � �gp���y7`Z.. <br /> Contact Person y� /�o <br /> Mailing Address �-'� s � � �D�c vl � C b LQ t2'� S� �. . <br /> `VATER SUPPLY <br /> Lake Well "✓� City <br /> BACKFLOW DEVICE � / <br /> . AVB PVB 'V <br /> � Year of <br /> _f � Make Model an f cture uanti <br /> Sprinklers �,�-�c,��lL- s , �u .►2� � <br /> � TOTAL <br /> HYDRAUL�C CALCITLATIONS Design Data: � <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprir�lclers: <br /> Total Water Required: GPM <br /> PERIVIIT FE� CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> 2. State $urchar�e $ .50 <br /> 3. Mail-In Fee . $ 1.50 <br /> 4. TOTAL PERMIT FEE (Add lines 1-3 above) $ '3�,S U <br /> The undersign�d 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 /> - Applic Date g`� �(� � <br /> ************�************* ***************�***********************�************** <br /> Approved M Q Approved with Corrections Denied <br /> Reviewed by: <br /> G� Date �'���� <br /> ^ �/V L hQC'(J �S`�v.�T' ��ArS Q�'IC/�' v.._.pf� COM��(}�Cl. <br />