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� Please check one: New �- Addition Limited Energy Technology <br /> Systems License # <br /> JOB SITE ,.�,>� �F,r 5`�a f Uq ��•1 <br /> Owner's Name ��i;� ��•{'i1 d�C�`S�''� Telephone Number <br /> Mailing Address_��� �� (��',�5�ct � �J�{U �� <br /> , <br /> Sprinkler Contractor's Name �j o��a:�� ��L%r`�yZ� Telephone Ntunber 7l�5�-�7.��/2? <br /> � <br /> Contact Person ��,� -�r�S <br /> ,�-� „ <br /> Mailing Address � 2 G_'j ���� �l =�� 7��.i�� '�1,n. ,�-�� <br /> WATER SUPPLY <br /> Lake� Well City <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture uant' <br /> Sprinklers �, ' �� ' ��. <br /> ��, �-�-,- f� 5 ��s � <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 Surchar�e $ .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 /> � n <br /> �� 1� �/i <br /> Applicant �,l� :7���'����z,,' �c�'_ Date �'' S - C�'-r, <br /> ******�*****�*********�**********�****************************�*****************� <br /> Approved Approved with Corrections Denied <br /> _ , �- , <br /> ReviewedBy: � ,. � , Date � <br />