1986, 05-27 Permit App: 00011237 Plumbing Fixtures.,767-36;> _�
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.
SIGNATURE OF APPLICATION
OWNER OR AGENTS DATE
Project M i>
Owner's Name Last
MI
\
W
Project Address (Street Name & Number)
City
State
Subdivision/ Plat Name
Assessors Parcel If
Lot
Block
Plat M
Applicant
Address
City
State
Zip
Phone
Business Phone
Contractor
(c
Address
((� �( g.-
M c w-t� e, .
City
State JZip
Phone
Contact
License M
Business Phone
Describe Work
Bar Sink (s):
Drinking Fountaln(s):
Floor Drain(s):
Washing Machine(s): /
Dsh Wshr(s): /
/
Garb Disp(s):
Kit Sink(s):
`
Lndry Tray (a):
Sew Eject(s):
Urinal(s):
WtrCloset (s):Lav(s):
Shower(s): /
1
Tub(s): l
Bidet(s):
W
Other: Type;
Ir
0
H
Waste/Grease Interceptor(s):
C
LL
11
O
Sewer Y N Septic/ Health No.:
w
M
Electric Water Heater (s) /
Drains -Roof:
Z
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.
SIGNATURE OF APPLICATION
OWNER OR AGENTS DATE