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i <br /> Please check one: New_�� Addition Limited Energy Technology <br /> Systems License# <br /> JOB SITE <br /> Owner's Name Telephone Number <br /> Mailing Address 17?Aj <br /> rinkler Contractor's Name Telephone Number �&c5?— <br /> C � <br /> Contact Person <br /> Mailing Address O — <br /> WATER SUPPLY <br /> Lake Well�� City <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture Quanti <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 convect. <br /> Applicant Date /a O <br /> Approved Approved with Convections Denied <br /> Reviewed By: `��� r Date <br />