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�i�o � � <br /> �iz y/c7 <br /> RECEIVEp <br /> MAY 2 3 2001 <br /> Please check one: New�_ Addition Limited Ener��'� <br /> . Systems License# L� �.� 7 <br /> � <br /> JOB SITE 2 � ��� �p �� J T'��� <br /> O�vner's Name ,b Z•+i(j' � ��4 c'f'�r" Telephone Number �/� ` .�C�`j- 7 7S� <br /> Mailing Address <br /> SprinklerContractor'sName/f���,r�il��,��j��y,!/���e�lep�ioneNurriber�.["�- ��t�.�,���'� <br /> Contact Person ��� �� <br /> Mailing Address�o� �� �'� ��'�; ,�,1'�� � �,y �o �y� . :f"�' �� <br /> WATER SUPPLY <br /> Lake Well_� City <br /> BACKFLOW DEVICE <br /> AVB PVB x <br /> Year of <br /> Make Model Manufacture uantit <br /> Sprinlclers r`,�-- ,�j' .�-� � <br /> �` �%y' � � � <br /> TOTAL 1� <br /> I�YDRAULIC 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 /> PERMI'I' FEE CALCULATION <br /> 1. Permit Fee $ 3�.00 <br /> 2. State Surchar�e � .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. 'I"OTAI,PE12I9�II'I' FEE (Add lines 1-3 above) � <br /> The undersigned hereby applies to the City for issuance of a Sprinkler System Perrnit, ag-rees 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 /> ,�S,a�. /�'`zl���l�;�%�! <br /> Applicant � � J') •��t, ��o�c��i�Jt>�1-' Date �� -� l � � � <br /> � <br /> ***�**X*********�*****�*�***�**�***�******��x��*�*******�*******�*��*��******�**� <br /> �ICee� <br /> Approved Ap�roved�vith Conections ��,GDenied <br /> Revie�vedB : ���'"""" ����` �-' Date '��� � <br /> Y � <br />