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�� �-3, �,6 ��o Z�Y <br /> �� � <br /> Please check one: New �/ Addition Limited Energy Technology <br /> Systems License # <br /> JOB SITE ��GC�� L��LL C �V f�s <br /> Owner's N ame •`J USC��I`� �5_ �{ZO N� Telephone Number y sol-��� -('(� <br /> Mailing Address �_S(-�N�(_.S <br /> SprinklerContractor'sName �j�� S(���k�� TelephoneNumber ��3� 0��,���7� <br /> Contact Person �5 A^^�� <br /> Mailing Address � �v� � (C.'�'� �U�g N - ��'�-�+`��'} 1'f�� .5 �7-� <br /> , <br /> WATER SUPPLY � <br /> Lake Well City <br /> BACKFLOW DEVICE <br /> AVB PVB ✓ <br /> Year of <br /> Malce Model Manufacture uanti <br /> �---� „ <br /> Sprinklers `�!� S'7v �'��= �a <br /> TOTAL �-E� <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: � U� U U d Sq. Ft. <br /> Coverage per Sprinkler: `�_Sq. Ft. <br /> No. of Sprinklers: �U <br /> Total Water Required: ���. GPM <br /> PERMIT FEE CALCULATION <br /> l. Pennit 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, 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 /> '';' ,: ' <br /> Applicant ��_, ' ' ��----.-.,.- Date 2( G�O <br /> *********�******* ************************************************************* <br /> Approved ~ prove � h ctions Denied <br /> V� ����r'� <br /> Reviewed By: Date b��� ����O <br /> Reset Form <br />