1986, 03-28 Permit App: 00010547 Plumbing Fixturesco
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
I Project 0
/05117
Owner's Name Last First MI
W12S CvnCJe
Proem Address (Street Name & Number)
231 el— S , Et'e ree \
City
State
Subdivision/Plat Name
Assessors Parcel tl
Lot
Block
Plat
Applicant
Address
City
I State
Zip
Phone
Business Phone
Contractor. ��C\ @UrKC 7 k�
Address.,
eo, (30 V 2651
/"
City State
SekaAe_ t,
Zip
9 r210
Phone
53c-00 6 6
Contact
License 0
Do \ -\i, C, P tA 1192-3J
Business Phone
5c.v---
Describe Work'
v`vm):,,..S`iO
Bar Sink(s):
Drinking Fountain(s):
Floor Drain(s):
Washing Machine(s):
Dsh Wshr(s): 1
Garb Disp(s):
Kit Sink(s): 1
Lndry Tray(s):
Sew Eject(s):
Urinal(s):
Wt Closet(s):
Lav(s):
Shower(s): /
/
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:
(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 provisions of any other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
APPLICATION
DATE 3 -.2tcr--C