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Please check one: New� Addition Limited Energy Techn ogy <br /> Systems License# �,�� <br /> JOB SITE ,���� �t�51�`� Pt- �d� � <br /> Owner's Name '�Y� �t w, n Telephone Number ���-?�_a�� <br /> Mailing Address o���5 �'�[S�.`) �-�-r <br /> SprinklerContractor'sName ����r� ���-�0'-TelephoneNumber �72y�/� <br /> Contact Person 4.-c�l'O <br /> MailingAddress - �S�7� (�'�' 5-�-, W��-�� <br /> WAT PLY <br /> Lake Well City <br /> ��__--�— <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers ��,�� <br /> ��, <br /> __ 1�1� � � �e <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 /> l. 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) � '2 � �"' <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 � ���� <br /> *****************�****�****�***********�***************�************�*********�** <br /> Approved � Approved with Corrections Denied <br /> _�,- <br /> Reviewed By: �``�� —� Date �J��`(�� <br />