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Please check one: New � Addition Limited Energy Technology <br /> Systems License# <br /> JOB SITE ����� � v�,'i ,���c„ C�k ,+.� 7;.y � �� i � ,___-� `7� <br /> Owner's Name ����,r�� c;��� L e � S< f ��� e c4�c,ti,�-� Telephone Number ��S�- 4�J 1 - Y��� <br /> Mailing Address 3 SU�1 �.��,n P���'� �„1 G,.n Z,;, 1�,, ��U S>�`j 1 <br /> Sprinkler Contractor's Name i`U�'a- Telephone Number G1 S 2 - 4 7l�- �S 7 F,�+ <br /> ContactPerson �U,��� +�-�i e� i���; � <br /> Mailing Address . � �r <br /> �VATER SUPPLY <br /> Lake Well City � <br /> BACKFLOW DEVICE <br /> AVB_� PVB � <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers _`r'� �� • �-. � ��" <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Desi Data: <br /> Area of Application: � n�;��' � Sq. Ft. <br /> Coverage per Sprinkler: I 27;�. Sq. Ft. <br /> No. of Sprinklers: ?S' <br /> Total Water Required: 1� S F�r 24 :�� GPM <br /> PERMIT FEE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> 2. State Surcharee $ .SO <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 /> � <br /> Applicant �'3'1,c Date (�-�- 3��- � � <br /> �, <br /> *********************** *** ***x�****************�*****�*�****��****************** <br /> Approved Approved with Corrections '� <br /> Reviewed By: � Date _ O �3 <br />