1984, 11-27 Permit App: 00003557 Plumbing Fixturesrn
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PLUMBING PERMIT APPLICATION WORKSHEET '
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU4UNDERSTAND
1 Owner's Name (Leat) (First) (M)
Department Use Only
/4CAOl X AfR/e/a Nr .5
Project No. 3 77
2 Project Address (Not Mailing Address) Space Zip
E—I// a9 gyo,Ve A V e g917,cc,
3 City/Community I State
S oka,e 1 6/N.
Subdivision/Plat Name
4 Assess Parcel No.
I Lot
Block
16 Contractor Firm Name
MucJ/er Pi6q G.
Street Address
570 oos0est-
17 Zip
.F9d 37
City
/
/4rcgc /o
State
GUy
Phone
(s29) 9:Cy-.x6DG
18 Coco t Person
License No.
Mile A 1-PIL,leod BB
Phone if different than above
8 Owner/Agent (If different than 41 above)
Business Address
9 Zip
City
State
Phone
( I
15 Describe Work: New O ; Addition/Alteration A ; Replace/Repair ❑
Total Number
of Fixtures:
10 Appli am//e
n'he r V. %% F? //e r
Stree Address q7
£ o o $ e I-
11 Zip Clty
X03 /VCreda/e
State
ms_
Phone
9 Bar Sink(s):
Drinking Fountain(s):
Floor Drain (s): >
Washing Machine(s): %
10 Dsh Wshr(s):
Garb Disp(s):
Kit Sink(s):
Lndry Tray(s):
/ /
Sew Eject(s):
11 Urinal (s):
Wt Closet(s): /
Lav(s): j
/
I Shower(s):
J
I Tub(s): /
Bidet (s):
Other: Type;
12 Waste/Grease interceptor(s):
13 Sewer V N Septic/Health No.:
14 Electric Water 'Heater (5):
Drains -Roof:
15 REPAIR OR ALTERATION: Drainage, Vent, Water Piping/Treatment: �V 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
OWNER OR AGENT
APPLICATION /�7 %C�
DATE