1984, 10-09 Permit App: 00002737 Plumbing Fixturesc in 1,0 See -Q11,01-
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0:ZC9 PLUMBING PERMIT APPLICATION WORKSHEET
' PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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1 Owner's Name (Last) / ' (First) (M)
Department Use Only
eelAir
Project No.
2 Project Address (Not Mailing Address) Space Zip
Ssc2i 7Z- 4Izj 4
3 City/Community
I State
Subdivision/Plat Name
4 Assessor Parcel No.
//
Lot
Block
2137
16 Cu for irm me Z // C
�'!/-N{� �
tState
Street Address e-.� w`
/0.203 £ T_ "�"�
17 Zip
4i�nseNo.
Phone
18 Cont nL
Phone if different than above
8 Owner/Agent (if different than 41 above)
Business Address
9 Zip
City
I State
Phone
15 Describe Work: New 0 ; Addition/Alteration 0 ; Replace/R pair 0
Total Number /0
of Fixtures:
10 Applicant Name
Street Address
11 Zip
City
State
Phone
9 Bar Sink(s):
Drinking Fountain (s):
Floor Drain (s):
(
Washing Machine(s):
10 bah Wshr(s):
Garb Disp(s):
Kit Sink(s): 1
Lndry Tray (ss)):
Sewl Eject(s):
11 Urinal (s):
Wt Closet(s): '7
.Lay(s): Z
Shower(s): t
I Tub(s): r
I Bidet(s):
t
Other: Type;
12 Waste/Grease Interceptor(s):
13 Sewer Y N Septic/Health No.:
14 Electric Water Heater(s): /
Drains -Root:
15 REPAIR OR ALTERATION: Drainage, Vent, Water Piping/Treatment: Y N
16 Lawn Sprinkler System (s), including backf low device on any one meter:
17 Vacuum breakers or backflow devices in excess of line 16:1-5:
(Or)5+:
imo Cr 4v
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
OWNER OR AGENT
APPLICATION
DATE /O 7 - i
251.5