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Please check one: New Addition Limited Energy Technology <br /> Systems License # <br /> JOB SITE 9 g s- 1,10 -3 <br /> Owner's Name tAA �� Vl C741- Telephone Number �1 S-2_-t/ <br /> Mailing Address <br /> Sprinkler Contractor's Name t 1'4Y1 Telephone Number 76' <br /> 22 <br /> Contact Person tck.vco <br /> Mailing Address - //D? 6) a / > e /4r <br /> WATER SUPPLY S <br /> Lake Well City <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> (___ Make Model Manufacture Quantity <br /> Sprinklers l <<itttiz�; <-( /1y 5-5- <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: 5 s <br /> Total Water Required: /Z, 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 \ 1�1� Date Cf-- -ma/ <br /> ********************************************************************************* <br /> Approved Approved with Corrections Denied <br /> Reviewed By: G)NiAl"i•-c- Date ) - -v L\ <br /> ( ,\ <br />