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�� �}--Ill�c� <br /> � ,� }. <br /> . ��.�: �w <br /> � ��� <br /> � <br /> Please check one: New�_ Addition Limited Energy Technology <br /> Systems License# <br /> JOB SITE �Z-C� �'? N��S��,ne p�' <br /> Owner's Name �it�,J�ia� .T i��� Telephone Number �l Z.c3'� j S�3� <br /> Mailing Address ,`jv�� <br /> Sprinkler Contractor's Name ' Telephone Number <br /> Contact Person �/����w,,, �,��% <br /> Mailin�Address � <br /> WATER SUPPLY <br /> Lake `C Well City <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture uantit <br /> Sprinklers �1-�-- �-��-�,�- �`fr�,,,,aLi— T�'Z? <br /> � , c� — � 3 <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: f QO v a Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: (Q�'� <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) $ -� 7�J � <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 � ��( °� <br /> ******�*****x�*****�****************��x�****�*********************************�*�** <br /> Approved _ " Approved with Corrections Denied <br /> Revie�vedBy: � Date � <br />