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Iq <br /> J,5"s o <br /> Please check one: New_ Addition Limited Energy Technology <br /> Systems License # <br /> JOB SITE 5q I N 5+Ma_m (�0 Q A <br /> Owner's Name t�o�� Telephone Numb4."9 52-) W7& -Z 1-7 <br /> Mailing Address Roo,cQ <br /> Sprinkler Contractor's Name e e Telephone Number(b l Z _ ©d <br /> Contact Person eY;a,-) e- <br /> Mailing Address m04 Q� /IA,in vg ee Q c S <br /> WATER SUPPLY ti� <br /> Lake Well_X City rc <br /> BACKFLOW DEVICE 1�`a <br /> AVB PVB X <br /> Year of <br /> Make Model Manufacture Quantit <br /> Sprinklers WU1451t P6Y Pre0 <br /> Pro - L <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: 2ao o o Sq. Ft. <br /> Coverage per Sprinkler: to 1 21 3u Sq. Ft. <br /> No. of Sprinklers: fa <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 Date "� J 0` - <br /> Approved /1" proved with Corrections Denied <br /> Reviewed By: GKa/,�- Date__ 6-6q <br />