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, - �'� (� �`�5 <br /> Please check one: New� Addition Limited Energy Technology <br /> Systems License# <br /> JOB SITE_ � 7 a 5 �c�_,c:�L c..+��'c�/.;� .�� / <br /> Owner's Name �r, 5 /l��"�:� Telephone Number <br /> MailingAddress I 7 ,�_� �'o.,v�'chP��.�.Z �T ���,v� <br /> Sprinkler Contractor's Name��T(.,�,.-� To c�,J -.��2 Telephone Number 7L 3--7�7 —O�,/�� <br /> Contact Person X� �� "�-% <br /> Mailing Address - l�1f i `� 7 G•�o t-� s � �% .%c/�.J �nv -tJ /��6���ls :'�..�/ <br /> `VATER SUPPLY ��S"�--/3 3 <br /> Lake Well City � <br /> BACKFLOW DEVICE <br /> AVB PVB�� <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers _ �u �7-�� %��.� G,� � �/� <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Desi�Data: , <br /> Area of Application: , '-�iC� Sq. Ft. <br /> Coverage per Sprinkler: _ S�� Sq. Ft. <br /> No. of Sprinklers: �� <br /> Total Water Required: /a GPM <br /> PERMIT FEE CALCULATION <br /> 1. 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) $ ��-�,� <br /> The undersigned hereby applies to the City for issuance of a Sprinkler System Permit, a�rees 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 /> c� , -� <br /> Applicant `____� . ' ���� .� �-�.�-� Date � - � ,��C%-S <br /> ***�******************�***************�******************�*********************** <br /> Approved Approved with Corrections Denied <br /> i <br /> Revie�ved By: ��� ���/L�r•-rt-�_ Date h��-� � �� 3 <br /> - �"�'t f1��(,�' Tli ��r� �;r.n.� � n��' � , �.< G�t �,��..��C'� , <br /> �. <br />