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�Q-�- �oo� --� ���' <br /> - s�-�z -� <br /> Please check one: New� Addition Limited Energy Technology <br /> Systems License# <br /> JOBSITE�7�{� Sh A��1�•um�� �cl D � /�O �<,t�, <br /> Owner's Name � ( /y��t,�r-� ��N �C�' - Telephone Number <br /> MailingAddress 5' O� �l,f C <br /> Sprinkler Contractor's Name � � C {� Telephone Number�'fr,'Z —��/��``7�8" <br /> Contact Person � v �C �. S��� .. � � ,D��� / <br /> Z 7� 5 <br /> Mailing Address(� 3� 9 4 � � ��j� � �.{ ��,�_ ✓ �� �� <br /> WATER SUPPLY <br /> Lake_� Well City <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: � / v�- �k � � T' Sq. Ft. <br /> No. of Sprinklers: '�� <br /> Total Water Required: _ � • �y GPM <br /> PERMIT FEE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> 2. State Surcharee $ .50 <br /> 3. Mail-In Fee $ 0 <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 Date ( 4 <br /> ************************************************************** ****************** <br /> Approved ✓ Approved with Corrections �� <br /> Reviewed By: �J Date �f ' `�-�� <br />