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�� 75 2-S <br /> .Please check one: New Addition � Limited Energy Technology <br /> � Systems License# �"�O���7 <br /> JOB SITE �5�� .l-�y t��CX'.� <br /> Owner's Name ��� l.�rQ�ac� Telephone Number �SZ�qy9- 1 I pt.► <br /> MailingAddress 36�(0 .J�l�� t�X�� <br /> SprinklerContractor'sName �o�ec�' IN��G�i,t�eb-4 1� TelephoneNumber �(�3-��o•-g981 <br /> Contact Person �rrir�. �}e��Tux31 d <br /> MailingAddress - �p �p,� IIq3 1�'jplP (��p�,l� �1n! 5531I <br /> WATER SUPPLY <br /> Lake Well City�_ <br /> BACKFLOW DEVICE <br /> AVB PVB C <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers I ofo ..�—f'r,'p�-I-,'on I��"S <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: Sq.Ft. <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: i„c� <br /> Total Water Required: 9-10 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) $ 37 00 <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 /> Applican Date 5-2�1-0� <br /> ***�**�*********��******� *�x**********�*******�x**********�****�***********�**** <br /> Approved Ml� proved with Corrections Denied <br /> Reviewed By: �°� Date ��Z� -� <br />