1986, 03-27 Permit App: 00010475 Plumbing Fixturesin
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PLUMBING PERMIT APPLICATION WORKSHEET Smote c
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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
DATE
• APPLICATIQ�L�27 8G
Project s //J 115
Owner's Name Last / �Firrst MI
Project Address (Street a e & Number) _,./.. J ,/j
,,r�, //t�t 604 v1
City
State
Subdivision/ Plat Name
Assessors Parcel p
Lot
Block
Plat e
Applicant
Address
City
1 State
Zip
Phone
Business Phone
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Business Phone
Describe Work
Bar Sink(s):
Drinking Fountain(s):
Floor Draln(s): /
Washing Machine(s): /
Deh Wehr(a): /
Garb Disp(s):
Kit Sink(s): /
Lndry Tray(s):
Sew Eject(s):
Urinal (s):
Wtr Closet(s): z
Levis): Z
Shower(s): /
Tub(s): /
Bidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer V N Septic/Health No.:
Electric Water Heater(s): /
Drains -Roof:
REPAIR OR ALTERATION: Drainage, Vent, Water PI ping/Treatment: V N
Lawn Sprinkler System (s), Including backllow device on any one meter:
Vacuum breakers or backflow devices In excess of line 18:1-5:
(005+ :
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
DATE
• APPLICATIQ�L�27 8G