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1986, 08-25 Permit App: 00012848 Plumbing FixturesC0 W CC D H X LL cc0 cc co m i Z PLUMBING PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND 1 Owner's Name (Last) (First) (M) Department Use Only a/Sod [ /`eW � Project No. /te4�,L/ S / 2 Project Address (Not Mailing Address) Space Zip 1/909 if . Fye Girt cit 9'92o6 3 City/Community Spam € State 644_9 Subdivision/ Plat Name 4 Assessor Parcel No. 0 2 Z) I Lot Block 16 Contractor Firm Namef�/ .//� ,,x//11 r�/J ,S / �/i,pv if es .G-n(State c Street Addressdr�7� , 7� /7( o •� Yel9t / 17 Zip `9zo6 5 Lae 0/194 Phone 1 ) ?2-e-9ovz 18 Contact Person License No TJ BE N--•273RL Phone d different than above 7 ed. LU,ic 8 Owner/Agent (if different than 01 above) Business Address 9 Zip City I State ll Phone 1 ) 15 Describe Work: New 0 ; Addition/ Alteration ❑ , Replace) Repair 0 Total Number. ? o1 Fixtures' 7 x 4 ._ 10 Applicant Name Street Address 11 Zip City State Phone 9 Bar Sink(s): Drink) g Fountaln(s): Floor Drain (s). Washing Machine(s) 10 Dsh Wshr(s): Garb Disp(s): Klt Sink(s)' Lndry Trlay(s): Sew Eject(s) 11 Urinal (s): Wt Closet (s): / / Lev(s): / Shower(s): I f Tub(s). % / I 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: 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+: 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. T - .ranting of a permit does not presume to give authority to violate or cancel the provisions local laws regulating construction or the performance of construction. SIGNATURE OF OWNER OR AGENT On - 2 -7— DATE APPLICATION �S f U