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, . �o�o�� <br /> - ��5� <br /> i <br /> Please check one: New Addition '' Limited Energy Technology y � <br /> Systems License #_/�"(�r� i;L ;� ,.: � <br /> JOB SITE �,;.� �j S ��G� 1'},�l S ,��- ��- <br /> Owner's Name_ �O'�I� ��'/��(I r� Telephone Number <br /> MailingAddress /--5�.� �� G; �S / �� /\ G'�� � �'� ti p <br /> Sprinkler Contractor's Name �'���:t- ;��'%'���J��(��. �r�` Telephone Number ��-=' :� ���-' � ° ��� <br /> Contact Person �;/�c 4��_�� �-����`��� <br /> � / _.��� , <br /> Mailin�Address , j��%.;� ��� .�'�.�,;; „�./��� , ��� __ � �� ��_ � ,�' :, _. �r,' � � ,�J .� i � <br /> `VATER SUPPLY <br /> Lake� Well City <br /> BACKFLOW DEVICE <br /> AVB PVB " S�t-"��j �- -- <br /> ` �' '��S' ► <br /> '� Year of <br /> Make Model Manufacture uantit <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 Surcharae $ .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 /> . �„ � <br /> Applicant -��% -/-%'� . ��� Date 'r - _ ;�/ <br /> � �, <br /> ******��*********�**:�*x�*********************�************************************ <br /> Approved `'� �/ p ved w' � 'ons �"' Denied <br /> ���C./�.1.�� ��C�;,� � <br /> � - f S �� S <br /> Reviewed By: Date <br />