1985, 03-18 Permit App: 00004583 Plumbing Fixtures•
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) (M)
.........---
)1Lk P- T )i,! %er'
Department Use Only
Project No.
2 Project Address ( of Mailing Address) Space Zip
Nt _.4L 7 -- i. 1-4.)5 Z 2 0
3 City/Community_
State
Subdivision/ Plat Name
4 Assessor Parcel No.
I Lot
Block
V583
16or Firm Nam
� . i&- ,x:1.1 -1<e e F791-.11,
Str Addre
f?', to x es 5:-/
1 17 _)
City y- �J
State �g Phone( -e.30
18 Contact Person jlI License No. Phone if different than above
, 1,7 -MW 5 0/ 402Nr.r
8 Owner/Agent (if different than 41 above)
Business Address
9 Zip
City
State
Phone
( )
15 Describe Work: New Addition/Alteration El; Replace/Repair ❑
Total Number
of Fixtures: if:
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
9 Bar Sink(s):
Drinking Fountain(s):
Floor Drain (s):
Washing Machine(s): /
10 Deh Wshr(s):
Garb Disp(s):
Kit Sink(s): /
Lndry Tray(s):
1 Sew Eject(s):
11 Urinal(s):
WtrCloset(s): \3
Lav(s):
i
Showr(s):
Tub(s):�
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
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DATECATION_j1,j/j
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