1985, 09-30 Permit App: 00007803 Plumbing FixturesCn
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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
J
Project No.
7
2 Project Address (Not Mailing Address)
Space
Zip
43ity/C.mm.nity
State
Subdivision/ Plat Name
4 Assessor Parcel N
Lot
Block
1fv6.7ractor FirmAlame
Stet Addr
17 Zip
City
State
Phone
18 Contact Person Licens o.
Phone if different than above
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
State
Phone
15 Describe Work: New; Addition/Alteration ❑
Replace/Repair ❑
Total Number
J
of Fixtures:
10 Applicant Name
Street Address
11 Zip
City
State
Phone
9 Bar Sink (s):
Drinking Fountain(s):
Floor Drain (s):
Washing Machine(s):
10
10 Dsh Wshr(s): j
Garb Disp(s):
Kit Sink(s):
Lndry -T
Sew Eject(s):
11 Urinal(s):
Wtr Closet (s):
Lav (s): "7
Shower(s):
Tub(s):
Bidet(s):
Other: Type;
12 Waste/Grease Interceptor(s):
13 Sewer y N Septic/ Health No.:
14 'E;ectfilt 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:
T(Or) 5+:
(Y9
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. `f
SIGNATURE OF APPLICATION —`
OWNER OR AGENT DATE !`
U