1986, 01-13 Permit App: 00009379 Plumbing Fixturesrn
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
IProject 3.7
Owner's Name —. Last First MI
Project Ad rasa (Street Na a Number)
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City
State
Subdivision/Plat Name
Assessors Parcel a
- -
Lot
Block
Plat If
Applicant
Address
City
I State
Zip
Phone
Business Phone
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Addr
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cit
ncit state
4-Y0 r..- 7.041
Zip
7907 (-)
Phone
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15 L3.S J rir)/;G-
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Licensee
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Business Phone
Describe Work
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Bar Sink(s):
Drinking Fountain (s): loor Drain(s): /
Washing Machine(s): /
Deh Wahr(s):
Garb Disp(s):
Kit Sink(s): /
Lndry Tray(s):
Sew Eject(s):
Urinal(s):
Wt Closet(s): �J , %
Levis):
Shower(s):
Tub(s):cz,
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: V 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 provisions of any other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
APPLICATION
DATE / l3 /�