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fr <br /> Please check one: New Addition Limited Energy Technology <br /> Systems License # <br /> JOB SITE O. 77( aZe:c-eZ <br /> Owner's Name c Telephone Number ' <br /> Mailing Addr ";fie . <br /> Sprinkler Contractor's Na;; a e f�_ - _ / _ Telephone Number 9 -9�/%//3 6 <br /> Contact Person �_ '� <br /> / <br /> Mailing Address / <br /> WATER SUPPLY <br /> Lake Well X City <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture Quantity <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 .v Date /4"/7 e <br /> Approved Ap, ov-d with Corrections Denied <br /> Reviewed By: C { ' N 1 Date 1 <br />