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t� A i . <br /> n <br /> , � I U �1��7 <br /> Please check one: New� Addition Limited Energy Technology <br /> Systems License# <br /> . <br /> JOB SITE 1�� �� ti–L.�,�,vot1/J <br /> Owner's Name�{?.o w �v, � �S 1!�f¢• Telephone Number <br /> Mailing Address �.N E , <br /> Sprinkler Contractor's Name � Telephone Number��','t..�iy��g <br /> Contact Person � <br /> MailinJAddress • G � i,�/ 7 � ,Q � �, „�s'3Yt� <br /> WATER SUPPLY <br /> Lake Well� City <br /> BACKFLOW DEVICE <br /> AVB�� PVB <br /> Year of <br /> Make Model Manufacture uantit <br /> Sprinklers �.— }�T f�?. �f" D <br /> —� <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 SurcharQe $ .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 certifzes that <br /> all statements made on this application are complete, true and correct. <br /> Applicant Date ���'d� <br /> T <br /> ********************�*�K********�k**�***#*�**��k*****�k*�k*�k** ***�k******�k*****�k***** <br /> � <br /> Approved ro ed�h ec ions ' Denied <br /> �lJ <br /> Revie�vedBy: ' Date � � `��� ��v <br />