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Please check one: New ✓ Addition Limited Energy Technology <br /> Svstems License# TS01388 <br /> JOB SITE <br /> , �'i ; <br /> Owner's Name 6l�: � I��-j� Telephone Number _15:�' ��� -����r <br /> Mailing Address�(�I �t�y� �G �� e v ' <br /> ,�� <br /> Sprinkler Contractor's Name _�1�('���tti� �Dy� `�������5 Telephone Number Gjfv� ���' �i`��%� <br /> Contact Person '���,,,� <br /> Mailing Address ���`l ,�'�'-���t I�J�L��� I�'l /�/��S� 1'�G�J 5.5 ��� � <br /> ✓ <br /> WATER SUPPLY �. <br /> Lake Well� City �� ��'�,1,1� �� <br /> J <br /> BACKFLOW DEVICE � <br /> AVB PVB_� �Iil�j`k��� 7�U��� <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers (y v` y,� <br /> �.'b� �'L'u - <br /> TOTa�, <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: �U;G'�� Sq. Ft. <br /> Coverage per Sprinkler: CC'U Sq. Ft. <br /> No. of Sprinklers: ��� <br /> Total Water Required: �� GPM <br /> PERMIT FEE CALCULATION <br /> l. Permit Fee $ 35.00 <br /> 2. State Surchar�e $ .50 <br /> 3. Mail-In Fee $ •�-5�-- <br /> 4. TOTALPERMIT FEE (Add lines 1-3 above) $ 3 �• `�� <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 ofthe City and State regulations,and certifies that <br /> all statements made on this application are complete, true and correct. <br /> Applicant�'L� Date � �v� ;�7�OS,►-- <br /> ********************************************************************************* <br /> Approved�T Approved with Corrections Denied <br /> Reviewed By: ��,���/ ,�?��i�6�' Date �— �� —�i� <br /> � Reset Form � <br />