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� 9 2qA� 5 �-Z5-bg <br /> 3 <br /> Zoog ._00 Zs� <br /> i Pleasd check one: New__Z_------Addition Limited Energy Technology <br /> Systems License # <br /> JOB SITE <br /> Owner's Name i Telephone Number :�—'_3 $�y �c tr <br /> Mailing Address <br /> Sprinkler Contractor's Name r CS,,,LAjTelephone Number <br /> Contact Person r I'll r-, <br /> Mailing Address G/ �— ��1�„� c �✓ �� � , { 2 S9 <br /> WATER SUPPLY <br /> Lake Well City <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture Quanti <br /> Sprinklers ,,, 6 PGi� d rs 3v <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 _ Date -ate <br /> ***** ** **** ************ **************************************************** <br /> Approved Approved with Corrections Denied <br /> Reviewed By: f Date <br />