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�-o ��c�c�q <br /> � �� . � <br /> � � <br /> Please check one: New l/ Addition Limited Energy Technology <br /> Systems License # <br /> JOB SITE .�%�c� ���t e� ���,� � <br /> Owner's Name � �r_,� �-�'�-,�_s��_s-c� Telephone Number <br /> Mailing Address �c,��� ��_ ��,� ��6� �,��,� _ {�-��� <br /> Sprinkler Contractor's Name �..�..„�_, ��r,,r,;r Telephone Number��; � �j 7�y, i�S'— <br /> Contact Person o j�_r� �„,� � <br /> MailingAddress • l/� S�- 21/f�-,•, �',l c� ^ 0�.z,,,�—/�/�," t^1��5`9 <br /> WATER SUPPLY <br /> Lake We11s��City <br /> BACKFLOW DEVICE <br /> AVB PVB � <br /> Year of <br /> Make Model Manufacture uantit <br /> Sprinklers �.-,,, ,�;- �e�� c �i' 7 S— <br /> � <br /> TOTAL �� <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: �s-- <br /> Total Water Required: �r-' GPM <br /> PERMIT FEE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> 2. State Surchar�e $ .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 /> ^ <br /> Applicant -� � Date ����q-c:i`� <br /> ********* **** *******�x** ***********�**�**************x�******************�** <br /> Approved�_ Approved with Corrections Denied <br /> ReviewedBy: ���cS f..,)�`��'``�^ Date �J�—V �'1 <br /> ; :; _ - _ - <br /> _ _ _ _ <br /> - C��� �� \��@'(�� �,1 wtc... Cwr-�llj-t <br />