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. <br /> Please check one: New� Addition Limited Energy Technology <br /> Systems License # <br /> JOB SITE �� �i.� � �"yS-i�..l k�c ,., �'� C`��(�;i ��� ; (l��t <br /> .) <br /> Owner's Name �-�-�1� �1^tCE'. Telephone Number <br /> Mailing Address ���, �; C i`�S�,1 �C� ��U- <"'I(�•i X'�� ��i�i <br /> Sprinkler Contractor's Name ���i��G�-n(� /�,��,��Y=;,y Telephone Ntunber�,� •- �/� '' (,:��'� <br /> Contact Person �'l;��n �'rS S <br /> Mailin�Address -Ni,�.�'v_ � `� t� ����I"(:� � /�>lC..` <br /> `VATER SUPPLY <br /> Lake�( _ Well City <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture uantit <br /> Sprinklers t-�v(1+�t-' a( � C L-- ,sS' <br /> I�-IL,R�� � ��-� ��. � c <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: f C Sq. Ft. <br /> No. of Sprinklers: �� <br /> Total Water Required: I.� I GPM <br /> PERMIT FEE CALCULATION <br /> l. Permit Fee $ 35.00 <br /> 2. State Surcharae <br /> $ .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 /> � <br /> Applicant /�' . �- ,��� � Date n'-5�G�S <br /> ********************�******��******��*�***********************�**************x�x�** <br /> Approved Approved with Corrections Denied <br /> Reviewed By: �ti, � � Date �� <br />