1986, 09-02 Permit App: 00012903 Plumbing Fixtures(n
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) (M)
I r'G'1lt / N. �a
Department Use Only
Project No.
2 Project Address (Not Mailing ddress)Space Zip
/ Y7 Al - cit5
3 City/Commu_ 1 State
Subdivision/Plat Name
4 Assessor Parcell o
I Lot
Block
16 Contractor Firm NameStreet
S4O PtutA4 Afie,
Address
/tigS-Serve
17 Zip
' �GIZb�
City
SPOIcam-e_
State
&J) 4
Phone
( )
18 Contact Person
12(/SS 0L2 C9(em
License No.
So PLU 1944. to14
Phone if different than above
8 Owner/Agent (If different than t/1 above)
Business Address
9 Zip
City
State
Phone
( I
15 Describe Work: New 0 ; Addition/Alteration Replace/Repair 0
Total Number
of Fixtures: c
10 Applicant Name
Street Address
11 Zip
City
State
Phone
(
9 Bar Sink(s):
Drinking Fountaln(s).
Floor Drain(s)..
Washing Machine(s):
10 De Wshr(s):
Garb Disp(s):
Kit Sink(s):
Lndry Tray(s):
Sew Eject(s):
11 Urinal(s):
Wt Closet(s): I
)
Lav(s): )
I Shower(s).
Tub(s)'
I l I
Bidet(sp
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+:
3 X L oo l`2- v O -F-C c,- 0 Pa 9p 0
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 �% APPLICATI
OWNER OR AGENT CI �dTJ� �/le DATE
A46