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• - ��7� ia <br /> Please check one: New Addition� Limited Energy Technology <br /> Systems License # <br /> JOB SITE <br /> Owner's Name r� �✓'��.s o >.l Telephone Number ��o� ��]/ & 6�3 <br /> MailingAddress_� � U C�J C� �/� /� �� �l�� Nv /�c� � <br /> Sprinkler Contractar's Name /�''6��. J,��.'r��Lt� Telephone Number 9S s(-S��fS`�0 6�� <br /> ContactPerson ,,C,�u ���� ��-�,��. <br /> MailingAddress_�v : � ;;2 n�� Ac�e , � : Sy1�k.op�e�t„ �eJ S,�.�79 <br /> WATER SUPPLY <br /> Lake �/ Well c�ty ,�x,s��v� L�^��r. �°�1r-z� T��s w��C.�. <br /> d� � /�' e Na t,iA�'��� a � .e,k�.f��N 6 <br /> BACKFLOW DEVICE � �t�� <br /> AVB PVB Y <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers �� (.s o � G'��d �, ��� 3 7 <br /> - /7rih rc %� � %7�f �0 � a � ''.3 / <br /> TOTAL s"� <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: �S`v <br /> Total Water Required: /o � GPM <br /> PERMIT FEE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> 2. State Surchar�e $ .50 <br /> 3. Mail-In Fee $ `�-�� <br /> 4. TOTAL PERMIT FEE (Add lines 1-3 above) $ :��, _.��`j <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 ✓ D�e // ` �� -- 0 � <br /> ************�***�*********************�**�***�***********�****�****�**�********** <br /> Approved�_ Approved with Corrections �� <br /> Revie�ved By: �1� '� 7 Date 1�- �� -'�� <br />