1985, 09-03 Permit App: 00007463 Plumbing FixturesU)
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r' 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
Project No.
2
Project Address (Not Mailing Address)
S
Space
Zip
3
City/Community State
Subdivision/ Plat Name
4
Assessor Parcel No.
1
Lot
Block
16 Contra Firm Name
! P
StP Address
17
Zip
City
State .
Phone
18 Con act Person License No.
r—
_J 1_1
Phone if different than above
8 Owner/Agent (if different than M1 above)
Business Address
9
Zip
City
State
Phone
15
Describe Work: New Addition/Alteration ❑
Replace/Repair f
otal Number
Fixtures: / �-
Ef
10 Applicant Name
Street Address
11
Zip
City
State
Phone
9
Bar Sink (s):
Drinking Fountain(s):
Floor Drain (s):
Washing Machine(s): /
`
10
Dsh Wshr(s): !
Garb Disp(s):
Kit Sink(s):
`
Lndry Tray(s):
Sew Eject(s):
11
Urinal(s):
WtrCloset(s):
�(
Lav(s):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:
(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 provision f Any other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF / APPLICATION
OWNER OR AGENT DATE