1986, 05-08 Permit App: 00011066 Plumbing FixturesPLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
IProject # ',v&O
Owner's Name Last First MI
ter%
Project Address (Street f�n & Number)
City
State
Subdivision/Plat Name
Assessors Parcel # (\ / / / D '/F /� / l
Lot
Block
Plat #
Applicant
Address
City
I State
Zip
Phone
Business Phone
Contractor
-`.1 t L 1A. . i ( ,-- k >a-_, PC/ } tt-
Addrgas
<ji & , 'a, X :;7z, /
City 1
_----)r/ kc,c.' e. ----,e.----,1,....4-;
State
/
Zip
C" _7G'
.
Phone
�`� �'� _ Zg2
Cont4t License #
J t/N RPtf /6 _i
Business Phone
Describe Work y
/C f .t ; x LE .t- C, I
Bar Sink(s):
Drinking Fountain (s):
Floor Drain (s): j
Washing Machine(s),
Dsh Wshr(s):
Garb Disp(s):
Kit Sink(s):
Lndry Tray(s):
Sew Eject(s):
Urinal(s):
WtrCloset (s):
Lav(s): ,
Shower(s): L
Tub(s): J
Bidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer Y N Septic/Health No.:
Electric Water Heater(s): { i
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:
I (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 provisions of any other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF t APPLICATION --
OWNER OR AGENT DATE ' � .//S7/‘