1985, 10-30 Permit App: 00008491 Plumbing Fixturesrn
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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. 1 i , .
SIGNATURE OF
OWNER OR AGENT
APPLICATION �/
DATE !��
Project # 1, r
f
Owner's Name Last
First
MI
Project Addr s (Street Name & Number)
City
State
Subdivision/ Plat Name
Assessors Parcel# �-
7,45 - )
Lot
Block
Plat #
Applicant
Address
City
State
Zip
Phone
Business Phone
ContracJQr__
� +*r �
Ad ess �-
City
State .,
Zip
Phone
�*
Contact)Licease
#
{__-_
Business Phone
Describe Work
BarSink(s):
Drinking Fountain(s):
Floor Drain (s):
Washing Machine(s):
Dsh Wshr(s):
Garb Disp(s):
Kit Sink(s):;
Lndry Tray(s):
Sew Eject (s):
Urinal(s):
WtrCloset (s): _
Lav(s): j' 1
Shower (s):
�Tub(s)
Bidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer y N Septic/ Health No.:
Electric Water Heater(s): (
Drains -Roof:
REPAIR OR ALTERATION: Drainage, Vent, Water Piping/Treatment: y N
Lawn Sprinkler System(s), including backflow device on any one meter:
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. 1 i , .
SIGNATURE OF
OWNER OR AGENT
APPLICATION �/
DATE !��