1984, 05-12 Permit App: 00000209 Plumbing Fixtures•
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last)" -7. (First) (M)
G4.' R r� e._ T . 41 /Ls
Department Use Only
Project No. I
2 Project Address (IWt(►vlailing Address) Space Zip
ie. �N17 2oc-Iv;k.f
3 City/Community
State
Subdivision/Plat Name
4 AQavor Parcel No.
I Lot
Block
16 races Fir afine� 14* te' g f' 1
StreetAddressg
4/,7
17 Zip
D ��z'4
City
5/,��j�k)
State
Ph e
) . � �
18 CopMrt Person v Lice3$e No. /
J1.?) IN. IA.., 'PZ2...-Ir k ______-- IJ %��%
Phone if different than above
8 Owner/Agent (if different than M1 above)
Business
Address
9 Zip
City I State
1
Phone
( )
15 Describe Work: New Addition/Alteration ❑ ; Replace/Repair I:
Total Total Number ��
of Fixtures:
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
9 Bar Sink(s):
Drinking Fountain(s):
Floor Drain(s): i
Washing Machine(s): /
1
10 Dsh Wshr(s):
Garb Disp(s):
Kit Sink(s): /
Lndry Tray(s):
Sew Eject(s):
11 Urinal(s):
WtrCloset(s):
Lav(s):
Shower(s): /
I Tub(s): ii
Bidet(s):
Other: Type;
12 Waste/Grease Interceptor(s):
13 Sewer Y N Septic/Health No.:
14 Electric Water Heater(s):
Drains -Roof:
15 REPAIR OR ALTERATION: Drainage, Vent, Water Piping/Treatment: Y 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
DATE //.