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•, ,j �` <br /> r ' '�� �i1�� <br /> � 1 <br /> � � <br /> s o <br /> Please check one: New Addition Limited Energy Technolo�y 1 <br /> ' Systems License#_�G�O �-e.o� <br /> JOB SITE � r� �� C�{� �lS /'�T, L.,I@ tiJ�., <br /> Owner's Name �e��� y �f� � �S Telephone Number 9��- �'�6 o-��3 0 <br /> Mailing Address 3 0� d. 0 �D �N S �r L A N� <br /> Sprinkler Contractor's Name /�b L�- -�i�/�•,�r4 �,�' Telephone Number ��r v`� '" ��',�r�J 6�� <br /> Contact Person ��^ca C�e._ G�Z��—. <br /> Mailing Address/t��L`� �',o�>���C�`t,+�"' ./d� � SC�� �$tI�, �, .��?A �oep� /"�6`1, <br /> WATER SUPPLY �.�3� � <br /> Lake Well lJ City <br /> BACKFLOW DEVICE <br /> AVB PVB � <br /> Year of � <br /> Make Model Manufacture uanti <br /> Sprinklers /o��','f'�`o (, ,�,5 4�� � � o� 3� <br /> /VeC.s��J �/'�8 - 6�Ja � 0 0 `� �D <br /> TOTAL � <br /> I�YDRAULIC 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 Surcharee $ .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 aze complete, true and correct. <br /> Applicant Date O ` �v�' � � <br /> �����x��*�*x����**��x�*���*���x��x ���*��*����x�������*�**��*�x����x��**�������x����x�����x <br /> Approved �� App oved with Corrections Denied <br /> a � <br /> Reviewed By: � Date �� �y�'o y <br />