1984, 06-10 Permit App: 00005897 Plumbing FixturesCO
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Leat) (First) (M)
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Department Use Only
Protest No.
2 Project Add (Not Mailing Address) Space Zip
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3 City/Community
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I Sta(e
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114
Subdivision/Plat Name
0 Assessor No
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Block657/
5e97
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street�(9 Cr S. c+C V -C/
17 zi
ason
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stat phone
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18 y License No.
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Phone If different than above
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8 Owner/Agent(If different than If1 hove)
Business Address
9 Zip
City I
State
Phone
( I
15 LblCribe Work: New yljlEltion/Alteration O
D 0 pL Replace/Repair ❑
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Total Number rgp/
of Fixtures. �J /C—J
10 Applicant Name
Street Address
11 Zip
City
State
Phone
9 Bar Sink(s):
pink) g Fountain/s):
Flow Drain(s):
Washi g Machlne(a): :./
V\
10 CetiWshr(ah
Garb Disp(e)
Kit SI nk(a): \
Lndry Tr y (sl:
Sew Eject(s):
11 IWinal(e):
WI Closet(s):
1
Lav(s): 4_
Shower(s): I
Tub(s): a
Ridel(5):
Other: Type:
12 V/este/Grease l nterceptor(s):
13 Sewer Y
N Septic/Health No.:
(�
14 Electric Water Heater(s): _ /
Drains-Roof:
15 REPAIR OR ALTERATION: Drainage. Vent, Water Piping /Treatment: Y N
16 Lawn Sprinkler System(s), Including backflow device on anyone meter:
s
17 Vswum breakers or baokflov devices in excess of line 16:1-5:
Mr) 5+:
l!o I79 -t°
I certify that the above information as submitted by me is true and correct and further, agree that all pro-
visions of laws and ordinances governing this type of work, including inspection requirements, will be corn -
plied with whether specified herein or not. The granting of a permit does not presume to give authority to
violate or cancel the provisions of any other state of local laws regulating construction or the performance of
construction. ^ /
OWNER
OF ^'f j , O ,a
OWNER OR AGENT IU IVN� ��`P'C,
APPLICATION p(
DATE UA74 i /D f /X L
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