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r Please check one: New Addition Limited Energy Technology <br /> Systems License # <br /> JOB SITE l� �� � b g <br /> Owner's Name Fjz! C- a ALLY �l ���- Telephone Number <br /> Mailing Address I �i4YNC�L <br /> Sprinkler Contractor's Name `K She-OJ3 Telephone Number 497--,0715 <br /> Contact Person 14;A9 f Gy, 1 <br /> Mailing Address o r :- Y� ,CW! 11M�C- (/Z .5-53 7 <br /> WATER SUPPLY <br /> Lake Well City n <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> / Make Model Manufacture uantit <br /> Sprinklers l k - k4p— joamet-,c 5 <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) $ 11 - (;,o <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- / 1�� �J¢Yt�l� Date <br /> Approved Approved with Corrections Denied <br /> Reviewed By: Q�VQ, Date -ZC)_ 0 <br />