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1986, 01-24 Permit App: 00009463 Plumbing Fixtures07 W 0 ILLX U. O cr W m Z 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 '�j APPLICATION OWNER OR AGENT DATE Project # r ; t; Owner's Name Last r st MI Project Address (Street Name & Number) r City State Subdivision/ Plat Name Assessors Parcel # Lot Block at # Appl icant Address City State Zip Phone Business Phone Contractor Address f 1 (, a y � a( ©.tet` City State // / ZiCp� + Phone Y/ _:3 :3 V Contact License # Business Phone Describe Work //� /1-1 /t 114C v u r ry /J� [rt 1-6 1.1 Lr (� / Bar Sink(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): Wtr Closet (s): 3 Lav(s): ,3 Shower(s): f Tub(.): Bidet(s): Other: Type; Waste/Grease Interceptor(s): Sewer y N Septic/Health No.: Electric Water Heater (s): �F} Drains -Roof: REPAIR OR ALTERATION: Drainage, Vent, Water Piping/Treatment: y N Lawn Sprinkler System(s), including backflow device on anyone 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 '�j APPLICATION OWNER OR AGENT DATE