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2 <br /> Please check one: New ��Addition Limited Energy Technology <br /> Systems License # <br /> � � <br /> JOB SITE �7G%= ' lr �.�j,,,�� ��R_ <br /> Owner's Name ,,,�_�,.., ,��rrs �c_r Telephone Number <br /> Mailing Address fs''7G'- ,�i�',�� ��s,r_��,-�..-e' [��{., <br /> Sprinkler Contractor's Name ��„�:.`j - c:���c Y Telephone Number � ; y�� !;�5--��`- <br /> Contact Person �A ,-r, �,� � <br /> Mailing Address - /��j` ��;., ��7'� L-�i, ij`�� �C ��f�,;� ,=��..5�� <br /> WATER SUPPLY <br /> Lake Well� City <br /> BACKFLOW DEVICE <br /> AVB PVB I/" <br /> Year of <br /> Make Model Manufacture uantit <br /> Sprinklers �/�, r�..-- �l�`� � ��� <br /> �;:. «.,� ff_r�� C� t� �r� <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 /> Applicant � � "� Date �-��-�°y- <br /> ******** �x**** �x******�*** ****�*********************�x�**�*************�*:�** <br /> Approved � Approved with Corrections Denied <br /> Reviewed By: v`�"�'� Date � `� � � � � <br /> _ . _ _ . _ _ _ - - <br /> _ _ _ _ <br /> _ <br /> C4\\ �er ;�5����t;��. `'''�-� -�,� S�•c _ _ _ _ <br />