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. <br /> . Please check one: New� Addition Limited Energy Technology <br /> Systems License# <br /> JOBSITE ���D ►v � � �"lD�� 4� � <br /> c y � �S2' <br /> Owner's Name �'� i � l,�}-�-�1'`ht.(` Telephone Number �� � � <br /> Mailing Address 3 S t O JU o r.�-h �I��B�rz Q (L,:� <br /> Sprinkler Contractor's Name ��sT� C�,r�,�E,S Telephone Number ��2�-a 3?— 3 y,3 <br /> Contact Person J�-{�n�-C_ ��J►c► ^/� <br /> Mailing Address . �`��0 0 �e.0 G�-�Jo'� Q R,�� ��'1�1P��m�Y� 5�3.3 � <br /> WATER SUPP Y . <br /> Lake Well City <br /> BACKFLOW DEVICE <br /> AVB PVB � <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers `�c�r�o S �sc� ��o.E.�,�,.. 3� <br /> S?c�• �d p �5 � :ti <br /> _ M.n', �S �f p i r-J�-r�w-�-w� �-i� �-E-..� l � <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: �v� o o c' Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: <br /> Total Water Required: 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, 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 /> Applicant ��-L ���'�S Date_ 7���/ � � <br /> ************** *******************************************�x********************** <br /> Approved Approved with Corrections �� <br /> Reviewed By: Date <br /> � <br />