1986, 08-25 Permit App: 00012848 Plumbing FixturesC0
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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)
Department Use Only
a/Sod [ /`eW
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Project No. /te4�,L/
S
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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