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Please check one: New Addition Limited Energy Technology <br /> Systems License# <br /> JOB SITE ZO 5 <br /> Owner's Name df VAU&,0111 Telephone Number <br /> Mailing Address 'Z�9_!r <br /> Sprinkler Contractor's Name XAA <br /> = &6t X e Telephone Number ?Y]2,z-37 fV &�p <br /> Contact Person O <br /> Mailing Address ,9/1 z <br /> WATER SUPPLY <br /> Lake Well_ City <br /> BACKFLOW DEVICE <br /> AVB _ PVB <br /> Year of <br /> Make Model Manufacture Quantit <br /> Sprinklers <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 Date / <br /> Approved �� Approved with Corrections Denied <br /> 4�,x <br /> Reviewed By: �l^- - Date -Zc -4 <br />