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`' � Please check one: New ./ Addition Limited Energy Technology <br /> Systems License# <br /> JOB SITE � k'�l_ �� - � y' (� <br /> � <br /> , <br /> , <br /> Owner's Name 71 Telephone Number C��%;�-J y�- �-���� <br /> Mailing Address 'ry <br /> Sprinkler Contractor's Nam� .���� �c�. �" l'��/ ��<JTelephone Number ��07- �1��0-/�/'� <br /> Contact Person ��� J /�?�.� <br /> g � �90 s��i���� � �� � ,C�"��� ���� �5.._3��5 <br /> Mailin Address �� <br /> J <br /> `VATER SUPPLY / <br /> Lake Well V City <br /> BACKFLOW DEVICE � <br /> AVB PVB <br /> Year of <br /> �.Make Model Manufacture uanti <br /> Sprinklers �-�,��?/�,t ' � �<'D� , , <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 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 are complete, true and correct. <br /> _, <br /> -� , <br /> ' �• ,_ . <br /> Applicant ' ����' Date �- ��- O� <br /> ***x�********�******************�» �*�*****************************************�** <br /> Approved Approved with Corrections Denied <br /> Reviewed By: " �`` " ��� G� � Date �'G� �' � � <br /> �'' C��1 � r � n5�<< �' . C ,� c'�� ��' Cc� (ti- �J' �� � — <br />