1986, 03-05 Permit App: 00009938 Plumbng FixturesPLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMM. ETE 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 provisions o anyp#her state of local laws regulating construction or the performance of
construction.
SIGNATURE OF _
OWNER OR AGENT /-)e
/_fit
APPLICATION,
DATE
Project k - -- -
Owner's Name _ _ Last First MI
Project Address/Street N aNumber)
,t, , !-'r7 I -r.) 4 -
City
State
Subdivision/Plat Name
Assessors Parcel #
Lot
Block
Plat #
Applicant
Address
City
I State
Zip
Phone
Business Phone
Cont104-.1"
-46 It i,L.- eR L.,_,r, 4 ____
Add ess
CitState
y
Zip
Phone
Contact P License # ______Business
;NOON /%2i s
Phone
Describe Work i—
i)— 1 X 'I- r't�" l -i
BarSink(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):
Wtr Closet (s):
Lav(s): 1
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 backflow 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 o anyp#her state of local laws regulating construction or the performance of
construction.
SIGNATURE OF _
OWNER OR AGENT /-)e
/_fit
APPLICATION,
DATE