1985, 06-10 Permit App: 00006020 Plumbing Fixtures PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Names (Last) f,. (First) (M) Department Use Only
IC-' -'1---- J-'4J Project No.
2 Project Address RJot Mailing Addre Space Zip
A), 1/9/7 /&t.-1--4)s ��
3 City/Community State Subdivision/Plat Name
4 Assessor Parcel No. I Lot Block
0626
16 for Firm Street Address /
o uz..��� i�-� / C. tie x a�S
•
17 Zip City State Phone
Z-- 2".v cCed)'a-A1 — Z.A.J.r/ ( ) fs ---. e‘, 4.
18 Contact Person V License No. one if different than above
1144P1 / JJ
8 Owner/Agent(if different than#1 above) ' Business Address
9 Zip City State Phone
( )
15 Describe Work: New A.; Addition/Alteration E ; Replace/Repair _ Total Number
of Fixtures:
10 Applicant Name Street Address
11 Zip City State Phone
( )
*
*
9 Bar Sink(s): Drinking Fountain(s): Floor Drain(s): ` Washing Machine(s): /
L 1
10 Dsh Wshr(s): Garb Disp(s): Kit Sink(s): / Lndry Tray(s): I Sew Eject(s):
11 Urinal(s): Wtr Closet(s): 3 Lav(s): 3 Shower(s): 1 Tub(s): ...2., Bidet(s):
co Other: Type;
W
CC
D
H 12 Waste/Grease Interceptor(s):
LL
tL 13 Sewer Y N Septic/Health No.:
O
CC
W
CO 14 Electric Water Heater(s): / Drains-Roof:
2 l
D
Z 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+:
1.) i (JU
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 APPLICATION �o ��„//
OWNER OR AGENT / DATE