1985, 09-09 Permit App: 00007377 Plumbing Fixturesrn
W
cccr
LL
0
cr
W
m
i
7
Z
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Nam$. (Last) -- first) (M)
Department Use Only 7....7vr�tie
in) ����/(�•
Project No
2 Project Ad ress (Not Mailing Address) Space Zip
E. //WoS ,rrAJVIJC •
3 City/Community I
State
Subdivision/Plat Name
4 Assessor Parcel No.��,Rq j�
. 6/D
I Lot
Block
16 Contrgrtyr Firm ame
�[/// CS r /
Street At1tlr
x (vs/
17 Zip /h„�� ity
cki
StateW.4 ,
Phone
18 Contact Person
Lina No
Phone if different than above
8 Owner/Agent (If different than 41 above)
Business Address
9 Zip
City
State
Phone
( I
15 Describe Work: New Addition/Alteration ❑ : Replace/Repair 0
Total Number (�
of Flxtures. /px(�%0%� JtZ
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( I
9 Bar Sink(s):
Drinking Fountain(s).
Floor Drain (s): )-
Washing Machme(s):./
10 Dsh Wshr(s)'
Garb Disp(s):
Kit Sink(s) '
Lndry Tray(s)
Sew Elect(s):
11 Urinal (s):
Wt Closet(s):
Lay(s): ag_I
Shower(s): /
Tub(s): /
Bidet(s).
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: .
(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 s ate of lorry laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
APPLICATION 7
DATE /