1986, 07-23 Permit App: 00012240 Plumbing Fixturesyr
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY TrilNOSE PARTS OF THE FORM YOU UNDERSTAND
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.1
1 /Owneernr'ss Name �`Qn(Last) (First) (M)
1.4— a C 7 A--Jti
Department Use Only
/7
Project No I2L
2 ProjectrA (Notke D�� Mailing Address)Space Zip
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3 City/Com nit Stat
Subdivision/Plat Name
4 aanevor Parcel No, I
Lot
Block
16 Can actor Firm Name
v2kt/k'elS %�j
Street Address �/
/�/1Q31/- .�3i-c
17 Zip��V6 ICny` 51,R2474 -me
V -me
State /�
Phone( ) 9 Yvl�G7
18 Contact Person Person
Licensee No. f//�[!////jL'�///��r!�x/�
Phone if different than above
8 Owner/Agent (If different than 111 above)
4
Business Address
9 Zip
City
State
Phone
1 )
15 Describe Work. New ; Addition/Alteration ❑ ; Replace/Repair ❑
Total Number
of Fixtures.
10 Applicant Name
Street Address
11 'Zip
City
State
Phone
I )
9 Bar Sink(s)'
Drinking Fountain(s)•
Floor Drain (s). i
Washing Machine(s). )
10 Dsh Wshr(s): / i
Garb Display
Kit Sink(s): /
Lndry Tray(s):
Sew Elect (s):
11 Urinal(s):
Wt Closet (s)'
Lav(s):
Shower(s):/
I Tub(s)' /
Bidet(s):
Other: Type;
12 Waste/Grease Interceptor(s):
13 Sewer Y N Septic/Health No.:
14 Electric Water Heater(s): /
Drams -Roof
15 REPAIR OR ALTERATION: Drainage, Vent, Water Piping/Treatment: V 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.
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SIGNATURE OF
OWNER OR AGENT
15
APPLICATION 7✓015 a
DATE