1985, 03-18 Permit App: 00004581 Plumbing Fixtures*
•
PLUMBING PERMIT APPLICATION WORKSHEET
• PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Nam (Last) .-----,, (First) (M)
,(1 �' -1/ y
1 (
Department Use Only
Project No.
2 Project Address (N iling Address Space Zip
p
3 City/Community
State
Subdivision/Plat Name
4 Assessor Parcel No. ILot
Block
ii55E /
16 Coffin [actor Firm Name
—moi 7)1t:ii _ ri r`ke./-
Str9e1 Address
f r k JL5"/
17 Zig 9 2 0
Cityp i7 l'e '
State '
Phone( `. '.SA�e� 6
18 Contactt PersoniI No.
I.�(/,�I p)4 »t _.
Phone if different than above
8 Owner/Agent (if different than #1 above) Business Address
9 Zip
City
State
Phone
( )
15 Describe Work: New A; Addition/Alteration I7; Replace/Repair ElTotal
Number / i
of Fixtures: ��1—
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
9 BarSink(s):
Drinking Fountain(s):
Floor Drain(s): J
Washing Machine(s): O
10 Dsh Wshr(s):
Garb Disp(s):
Kit Sink(s): /
Lndry/Tray(s):
Sew Eject(s):
11 Urinal(s):
Wtr Closet(s): 3
Lav(s): 3
Shower(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
ffl
APPLICATION
DATE