1985, 11-07 Permit App: 00008903 Plumbing FixturesPLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
I Project #
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Owner's Name � Last i First MI
umber)
Project Addres, (Street Nam4& ----7
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City
State
Subdivision/Plat Name
Assessors Parcel #
Lot
Block
Plat #
Applicant
Address
City I
State
Zip
Phone
Business Phone
Co
Adcjceis
C1ty State I
Zip
Phone
ntact
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Lics,me #
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Business Phone
Describe Work l
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Bar Sink(s):
Drinking Fountaln(s):
Floor Drain (3):/
Washing Machine(s): /
Dsh Wshr(s):
Garb Disp(s):
Kit Sink(s): /
Lndry Tray(s):
Sew Eject(s):
Urinal(s):
WtrCloset(s): •"--7
Lav(s): !!
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Shower(s): / J
Tub(s): /
Bidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer Y N Septic/ Health No.:
Electric Water Heater(s):
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 herd or not. The granting of a permit does not presume to give authority to
violate or cancel the provision of ar)y :t er state lcal laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
APPLICATION //1
DATE