1985, 08-07 Permit App: 00006728 Plumbing Fixtures.7
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
GN`a�me / —//I (Last) (M)
/ Ie
Department Use Only
Project No.
m
C ' ` OTA 1/t Sit l
r Project Apdr:tib); (Not M Rg, e� 111 Space Zip
3 City/GCoommuu/�foiily I State
at—,
�r
Subdivision/Plat Name
4 Papel
I`v c
I Lot
k
&796'
16 Co tractor vm Name
iit• �s �Cvrizb�,v�
Street Address
/I/186) R>9, lel
17 Zip qir?) I
I City �pvk/ "-"
(state _ ')
f/iC♦�u�/
Phone( ) �� e7,566
18 Contact Person
License No.
--)tni es
PE/S---,3‘ )3 5
Phone d different Than above
8 Owner/Agent (if different than 01 above)
Business Address
9 Zip
City
State
Phone
( )
15 Describe Work: New ❑ ; Addition/Alteration
Replace/Repair ❑
Total Number
of Fixtures.
10 Applicant Name
Street Address
11 Zip
City
State
Phone
9 Bar Sink(s):
Drinking Fountain(s):
Floor Drain (s):
Washing Machi ne(s).
10 Clsh Wshr(s):
Garb Disp(s).
Kit Sink(s): /
Lndry Tray(s)'
Sew Efect(s):
11 Urinal (s)'
Wt Closet(s) /
Lav(s): /
Shower(s): /
I Tub(s):
Bidet(s).
Other: Type; -
12 Waste/Grease Interceptor(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 any one meter:
17 Vacuum breakers or backflow devices In excess of line 16'1-5:
(Or)5+
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 com-
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.
SIGNATURE OF APPLICATION
OWNER OR AGENT AZ, �/ i DATE