1986, 02-24 Permit App: 00009800 Plumbing FixturesPLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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Project # qer
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Owner's NameLast First MI
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Project Address (Street N ne & Number) --7
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City
State
Subdivision/Plat Name
Assessors Parcel #
Lot
Block
Plat #
Applicant
Address
City
I State
Zip
Phone
Business Phone
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Phone
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Describe Work
Bar Sink(s):
Drinking Fountain(s):
Floor Drain (s): /
Washing Machine(s):
Dah Wshr(s):
Garb Disp(s):
Kit Sink(s): /
Lndry Tray(s):
Sew Eject(s):
Urinal(s):
WtrCloset(s):
G^
Lav(s):
Shower(s): /
Tub(s): /
Bidet(s):
W
2
Other: Type;
n
XWaste/Grease
Interceptor(s):
it
O
CC
Sewer Y N Septic/Health No.:
W
COElectric
Water Heater(s): /
Drains -Roof:
D
Z
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:
(005+ :
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 provision . ther state of local laws regulating construction or the performance of
construction. /
SIGNATURE OF
OWNER OR AGENT
APPLICATION
DATE