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. � � <br /> Please check one: New� Addition Limited Energy Technology <br /> Systems License # <br /> JOB SITE �%O li1 ,c /�L��/ 2�1'S �j 5 A iv,�s�i...� c�!�o...f <br /> Owner's Name Telephone Number <br /> Mailing Address <br /> Sprinkler Contractor's Name y1r��:�1,� ���<< �� f- L,,���<��Telephone Number �C � y��� _X j �'�, <br /> / <br /> ContactPerson�,%�� ��, 5�,�2.L:�[lj L <br /> � � � - , <br /> Mailing Address ��x' �,��% � J 1 ;y� ����3 � <br /> ��J G� � .T1��= � � :� <br /> WATER SUPPLY <br /> Lake Well City�_ <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture uantit <br /> Sprinklers �����,-- i�� i� ��' �/ <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: j(,J Sq. Ft. <br /> No. of Sprinklers: <br /> Total Water Required: � Q� 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 C� <br /> **********�***************�x*****�***�*****��x****�x*****�************x�*��*******�** <br /> Approved p� Approved with Corrections Denied <br /> Reviewed By: �� l�C�-- Date � ``�'���1 <br /> _ __ _ _ _ - <br /> _ _ _ _ _ _ _ _ _ _. <br />