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Please check one: Ne�v Addition i./ Limited Energy Technolo�y <br /> Systems License# � �� U d'�'� � `� <br /> JOB SITE <br /> O�vner's Name �/O � �j�r�/n`�J Telephone Number ��� � �� ���f� <br /> Mailing Address o( 7� (> CvGc,tJ l�"/S'i d �- ��', �`� : <br /> Sprinlcler Contractor's Name ����t, _�p��-�:�,i' � Telephone Ntunber ��� ��'�,;�. `��S � <br /> ContactPerson ,��i��� c_r�_, ���,�Y- <br /> Mailin�Address �/�� � �'',GJ � /S' U'e ' ,�": S/�'����k '�� ��1�• � S � 7 9 <br /> `VATER SUPPLY / <br /> Lake Well ✓ City <br /> BACKFLO`V DEVICE <br /> AVB PVB `� <br /> Year of <br /> Make Model Manufacture uantit <br /> Sprinklers �,(���. (,J o �� :�'/i�_d 5 0 �� �J o,.� v o <br /> �r-r,"7'r.: ( . f`�S �!-ov 6���S � <br /> TOTaI., �4 <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 /> P]ERIVIIT FEE CALCULATION <br /> ' 1. Permit Fee � 3�.00 <br /> 2. State SurcharQe � .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. �'O�'AI.PE1210-'I3T' �'E� (Add lines 1-3 above) � <br /> The undersigned hereby applies to the City for issuance of a Sprinkler System Permit, a�rees to do <br /> all�vork in strict accordance with the ordinances of the City and State re�ulations, and certifies that <br /> all statements made on this application are complete, true and correct. v <br /> Applicant � Date �� -- /-�"" � '� <br /> �**�**X*�***�***���*�***�******�***��****���x����***�*�*�*�*��**�****��*�****��** <br /> w:�� Pr;;�;c�� <br /> Approved Approved with Conections�ln �1 S i3�, ,r Denied <br /> -�� �� �ny <br /> Revie�ved By: �� ,�, �� Date � -1�S 't�F� <br />