1986, 08-15 Permit App: 00012740 Plumbing FixturesPLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
IProject N
<��-I�)
/21.17.0
Owner's Name Last First MI
kg Alt
Project Address (Street Name & r)
S I4aa 0 kisiciAteuyn
City
State
Subdivision/Plat Name ,
Assessors Parcel N
Lot
Block
Plat N
Applicant
Address
City
I State
Zip
Phone
Business Phone
Contractor -_ o(�
n^
Address
City
State
wen
Zip
49a0q
Phone
466 -"la 39„
Contacts
Licensee
�hzcp�i 1$ 03
Business Phone
S61ME
DescribeWork ` "t
R• ,
Ber Sink(s):
Drinking Fountaln(s):
Floor Drain(s):
Washing Machine(s): I
Dsh Wehr(s):
Garb Disp(s):
Kit Sink(s):
Lndry Tray(s):
Sew Eject(s):
Urinal(s):
Wtr Closet(a): 3
Lav(s): ...1 ?
Shower(s):
Tub(s): 1
Bidet(s):
Other: Type; ,
Waste/Grease Interceptor(s):
Sewer V N Septic/Health No..
Electric Water Heater(s):
Drains -Roof:
REPAIR OR ALTERATION: Drainage, Vent, Water Piping /Treatment: V N
Lawn Sprinkler System (s), Including bead low device on any one meter:
Vacuum breakers or backflow devices In excess of 11110 16:1-5.
(005 + :
�'i4=36: ^LIS..•`a SI."
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 8-15-8 lo