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� ����� ��� <br /> . • - f-� //5C� y l�``%//��1� <br /> 3� � <br /> Please check one: New� Addition Limited Energy Technology <br /> Systems License # [,(�j��� <br /> JOB SITE � � �,S /� �,�/ �/O o�� G�I� t,� <br /> i3'v�/�! ,�-,r �t��/-�� ',�f'�i'lr- <br /> Owner's Name�4�J�" 01��1<� �iP� , ; 1�r�,i lelephone Number _ <br /> Mailing Address �IO �7 ,�"• �✓����f� ,�i��� �t ,�Y�,- �!-"�1 �s.�r? �T,t�Jf.,�/ �'r�j <br /> SprinklerContractor'sName�/����,.����,,-,y��h�,�,�/�,,.�'elephoneNumber 7G��- C/�%-r`�� <br /> Contact Person���������,-�� _ <br /> Mailing Address�'�� �,�� ,�1�r �/ ��/�IG,J��' ��n v�', ,��--�f,��/ <br /> � <br /> WATER SUPPLY <br /> Lake Well City �� <br /> BACKFLOW DEVICE <br /> AVB PVB _� <br /> Year of <br /> Make Model Manufacture uantit � <br /> Sprinklers �:: .�,r�' /.i �'� .S����� .l`�,y%�rf' -- 2� <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: Sq. l�t. <br /> No. of Sprinklers: Z G <br /> Total Water Required: �� GPM <br /> � <br /> PERMIT FEE CALCULATION <br /> 1. Permit Fee � �i5,�(� <br /> 2. State Surchar�e � .�0 <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 Per-mit, a�rces �o 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��_�/_..,.�_ __ _ <br /> **************** *****�x********************************************************** <br /> Approved / W p ed witl�Qo ' ns Denied -- ___ <br /> �J <br /> Reviewed By: Date � -�t� Q� <br /> Reset Form <br />