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°CC a � <br /> Please check one: New //' Addition Limited Energy Technology <br /> �f i J l ` Systems License# <br /> �/ <br /> JOB SITE / / �/ 1 ILL° \1 „xi <br /> Owner's Name I w ;, �Nc44 j CIC. Telephone Number <br /> Mailing Address <br /> Sprinkler Contractor's Name E t v it L„`I 4crimbejie Number 76,3- §'72_,-2.2 �( <br /> Contact Person A�,.4 �+ \A/ Gl L �V <br /> Mailing Address tie,3C) k_d II SE <br /> WATER SUPPLY <br /> Lake Well City <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture Quantity <br /> Sprinklers tlefiii 77 rci y 05- <br /> TOTAL 5TOTAL <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: - /2 GPM <br /> PERMIT FEE CALCULATION <br /> 1. Permit Fee S 35.00 <br /> 2. State Surcharge S .50 <br /> 3. Mail-In Fee S 1.50 <br /> 4. TOTAL PERMIT FEE (Add lines 1-3 above) S <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 t Date /P <br /> - <br /> *************** **************************************************************** <br /> Approved Approved with Corrections Denied <br /> Reviewed By: ,C Date ( 0 `' 3 -CJS <br />