1985, 12-02 Permit App: 00009004 Plumbing FixturesEn
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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 ar�ypther state of local laws regulating construction or the performance of
construction,
SIGNATURE OFi APPLICATION
OWNER OR AGENT -'-�%' — DATE
Project #
lef'��`
Owner's Name Last a
First
MI
Proj Address (Stcae; Name 8 Number)
City
State
Subdivision/ Plat Name
Assessors Parcel#
IIII
Lot
Block
Plat #
Applicant
Address
City
State
Zip
Phone
Business Phone
Ce,,tfa—qtor _�
Addr
City -_
State
Zip
Phone
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Contact
Lice
Business Phone
s -
-
Describe Work
BarSink(s):
Drinking Fountaln(s):
Floor Drain (s):
Washing Machine(s): `
Dsh Wshr(s): i
Garb Disp(s):
Kit Sink(s):
FLndry Tray(s):
Sew Eject(s):
/,
Urinal(s):
Wtr Closet (s): "�
Lav(s): -;
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 ar�ypther state of local laws regulating construction or the performance of
construction,
SIGNATURE OFi APPLICATION
OWNER OR AGENT -'-�%' — DATE