1985, 08-08 Permit App: 00006848 Plumbing Fixtures•
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Ownar'a (M)
t
'sooty— �/o
Department Use Only
rl[,9}/1R:1.1A0.N/ame
&t S/rat)
Project No.
2 Project Address (Not Mailing Address) Space Zip
1924 5 «- jJ i., p Yi V e.
3 City/Community
56 /Co Ale
I Stattef�Q /
Subdivision/Plat Name
4 Assessor arcel No. (6254)
Lot
Block
teirn
16 Contractor Firm%rilme /�—^ ""///�11 _ '7""� ,/
/ ./- 1-i� P/7��Yl i S -fes Nc
Streetet%Adddress^? '7-��
(�/ h� / E - / Yexl f
17 Zip
1
enzo 6,
State
Phone
18 Contact Person
—7--ec l Ct.�a/
License No.
77-13E 4- 273EL
Phone if different than above
8 Owner/Agent (If different than 41 above)
Business Address
9 Zip
City
I State
Phone
15 Describe Work: New A Addition/Alteration 0 ; Replace/Repair ❑
Total Number
of Fixtures a r—
10 Applicant Name
Street Address
11 Zip -
City
State
Phone
9 Bar Sink(s):
Drinking Fountain(s).
Floor Drain(s).
Washing Machine(s). r
/
10 Dsh Wahr(s): /
Garb Disp(s):
KitSink(s): /
Lndry Tray(s) / I Sew Eject(s):
11 Urinal(s):
Wt/Closet(s). „2_, ,
Lay(s): 3
Shower(s). ,
I Tub(s) 02,
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:
(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.
SIGNATURE OF
OWNER OR AGENT
APPLICATION C
DATE O �/ i