1986, 05-08 Permit App: 00011063 Plumbing FixturesPLUMBING PERMIT APPLICATION WORKSHEET
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 provision •f - rry other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
APPLICATION
DATE
Project # / / D(,3
Owner's Name First MI
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Project Addr s (Street Name N ber)
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City
State
Subdivision /Plat Name
Assessors Parcel # / !� (,yw/ '/7
Lot
Block
Plat #
Applicant
Address
City
I State
Zip
Phone
Business Phone
Contractor_... ---;i ' j
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Addr�9 ,-.
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City
State
Zip
Phone
Cont License #-
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Business Business Phone
Describe Work
/1,7) L - I K-} i_c_ r, 3
Bar Sink(s):
Drinking Fountain(s):
Floor Drain(s): /
Washing Machine(s): /
Dah Wshr(s):
Garb Disp(s):
Kit Sink(s): /
Lndry Tray(s):
Sew Eject(s):
Urinal (a):
WtrCloset (s):
Lav(s): ____
Shower(s): /
Tub(s): `
Bidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer Y N Septic/Health No.:
Electric Water Heater(s): /
Drains -Roof:
REPAIR OR ALTERATION: Drainage, Vent, Water Piping/Treatment: Y N
Lawn Sprinkler System(s), including backflow device on any one meter:
Vacuum breakers or backflow devices In excess of line 16: 1-5:
(00 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 provision •f - rry other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
APPLICATION
DATE