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a <br /> . <br /> Please check one: New Addition Limited Energy Technology <br /> Systems License# <br /> JOB SITE (� <br /> Owner's Name �__i� ��'�� • Telephone N ber <br /> � <br /> Mailing Address <br /> Sprinkler Contractor's Na Telephone Number�S�-�y/.-//,j d <br /> Contact Person <br /> Mailing Address - G�r/ • <br /> WATER SUPPL <br /> Lake Well City <br /> BACKFLOW DEVICE <br /> AVB PVB <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers � �- a <br /> � , <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Desi�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 Surcharee $ .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. TOTALPERMIT 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 /> �� <br /> Applicant Date U � <br /> **********�*********************************�*****�*******�**************�**�*�** <br /> Approved r�� Approved with Corrections �� <br /> � <br /> Reviewed By: G���� I���� Date �- ��_C�� <br /> !�/�.�c� ;��r�cr;�^ r�-�r ��r-��c.�:�t� <br />