1986, 03-31 Permit App: 00010279 Plumbing Fixturesm
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (First) IM)
Lastt)/
' Department Use Only
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Project No /Ci./vg
2 Project Address (Not Mailing Address)/� s Space Zip
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3 City/Community I State
Subdivision/ Plat Name
4 Assessor Parcel No.
I Lot
Block
16 Contractor Firm/ ame _ ,, I LIQ ,,rr�'Street
�1 .b' iv' / CV) SeS _nit)State
Address 7
/ o / g_ 7 -vent .�
17 Zip p�Phone
1 / Zd�v
I S,v active l- i
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18 Contact Person License No
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Phone if different than above
8 Owner/Agent (If different than #1 above)
Business Address
9 Zip
City
I State
Phone
15 Describe Work: New Addition/Alteration 0 , Replace/ Repair LI
Total Number / /1�/
of Fixtures l�4- rjz
10 Applicant Name
Street Address
11 Zip
City
State '
Phone
I )
9 Bar Sink(s)'
Drinking Fountain(s).
Floor Dram(sp
Washing Machine(s)• /
10 Dsh Wshr(s): .
/
Garb Disp(s):
Kit Sink (s). /
Lndry Tray(s).
/
Sew Ejectis).
11 Urinal (s):
Wt Closet(s): ci
Lay(s). 1Shower(s).
/ �
Tub(s)' /\
i
Bidet(s):
Other: Type;
12 Waste/Grease Interceptor(s):
13 Sewer V N Septic/ Health No..
14 Electric Water Heater(s):
(.
Drains -Roof:
15 REPAIR OR ALTERATION: Drainage, Vent, Water Piping/Treatment: V N
16 Lawn Sprinkler System(s), including back( low 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 otos- tate of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
APPLICATION 3/?//,‘
DATE