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Please check one: New )( Addition Limited Energy Technology <br /> A , ' pI Systems License# <br /> JOB SITE Ya /7 /V 4n �' 5 A 0?A �r,\,4 (pY©m an <br /> Owner's Name jo 1-Y)s(rift cSo-2t. <br /> Telephone Number <br /> Mailing Address °/ 7 No bore, 010Y) <br /> Sprinkler Contractor's Name 7 'YY1Ct e et Telephone Number 252 L/V1 - /77 ' <br /> Contact Person GCS_c ( Gom�� <br /> Mailing Address J-jl j L/a n d 2 c) p 7' <br /> WATER SUPPLY \J <br /> Lake y Well City <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture Quantity <br /> Sprinklers <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 Surcharge $ .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 CX�7 Date low 0 n <br /> ****************** ************** 4411****************************************** <br /> Approved pp Approved with Corrections Denied <br /> Reviewed By: (LI 1 'Zp5 Date 7''/2 6 7 <br />