1986, 03-26 Permit App: 00010259 Plumbing Fixtures0,
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PLUMBING kERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) (M)
L /
M Vo-tr.-4. (M1e Lart
if
Department Use Only
n.��
Project No /✓.4-`il
2 Project Address (Not Mailing Address) Space Zip
3coa--}5—o¢ J,. biek
3 City/Community
PAL I l w d c D
State
LAM -
Subdivision/Plat Name
4 Assessor Parcel No.
I Lot
Block
16 Contractor Firm Name
f1-1 p(nt IJN A. b 1N)
Street Address
36x ad 3
17 Zip
19 day
Ci
1 rvo".�- lie-
State
Phone
(a?o) 619 S'--
18 Contact Person
)1�1-.J c 4 �Luy}u
License No.
4-I %7fn/p /!8)4
Phone if different than above
8 Owner/Agent (If dif t than 1/1 above)
Business Address
9 Zip
City
State
Phone -
(
15 Describe Work: New ; Addition/Alteration 0 ; Replace/Repair ❑
y.
Total Number /2
of Fixtures -
10 Applicant Name T
.l 1 Pr& .- l l ✓1kl'J
l/
Street Address
11 Zip
City
State
Phone
( I
9 Bar Slnk(s):
Drinking Fountain(s):
Floor Drain (s).
Washing Machine(s): L
10 I3sh Wshr(s)'
Garb Disp(s).���
Kit��,Sink(s): Z
Lndry Tray(s):
Sew Eject(s)'
11 Urinal (s):
Wt Closet (8). µ
///
Lav(s): r+
Shower(s): I.L.
I Tub(s):
Bidet(s).
Other: Type;
12 Waste/Grease Interceptor(s):
13 Sewer Y b Septic/Health No.:
14 Electric Water Heater(s): 'L
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-.:
7,=7ariS ST7
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
APPLICATION
DATE 3- Z4 _ 84