1986, 05-08 Permit App: 00011065 Plumbing FixturesPLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
` I Project M I / 1)65
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Owner's NameLast First MI
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Project Address (Str Na e & Number) ,.----7 r
City
State
Subdivision/Plat Name
Assessors Parcel M
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_Lot
Block
Plat #
Applicant
Address
City I
State
Zip
Phone
Business Phone
Contractor
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Address
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City
State -)
Zip Phone
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License # Business Phone
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Describe Work
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Bar Sink(s):
Drinking Fountain(s):
Floor Drain (s):
Washing Machine(s): /
Dsh Wshr(s):
Garb Disp(s):
Kit Sink(s): /
Lndry Tray(s):
Sew Eject(s):
Urinal(s):
WtrCloset(s):
c1
Lav(s):
.
Shower(s):
Tub(s): /
Bidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer Y N Septic/Health No.:
Electric Water Heater(s): j
/
Drains -Roof:
REPAIR OR ALTERATION: Drainage, Vent, Water Piping/Treatment: Y N
Lawn Sprinkler System(s), including backf low device on any one meter:
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
DATE