HomeMy WebLinkAbout1985, 01-08 Permit App: 00003910 Plumbing Fixturesw
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's�e (Last) - . (First) (M)
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Department Use Only
Project No.
2 Project 'Address (I of aailin Address Space Zip
3 City/Community
State
Subdivision/Plat Name
4 Assessor Parcel No. I
Lot
Block
16.10.1xactoi Firm Name
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17 Zip
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City
SSE% ,C.
State 1
./x. '
Phone
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18 ntact Person Licens No.
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one if different than above
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
State
Phone
( )
15 Describe Work: New ID; Addition/Alteration El; Replace/Repair E
Total Number
of Fixtures: /A
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
9 Bar Sink(s):
Drinking Fountain(s):
Floor Drain(s):
/
Washing Machine(s):
10 Dsh Wshr(s):
Garb Disp(s):
Kit Sink(s):
/
Lndry Tray(s):
Sew Eject(s):
11 Urinal(s):
WtrCloset(s): /'7 �J
Lav(s): 3
Shower(s):
1 Tub(s):
Bidet (s):
Other: Type;
12 Waste/Grease Interceptor(s):
13 Sewer Y N Seeeptic/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 provisio of y other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
APPLICATION
DATE