1986, 08-15 Permit App: 00012683 Plumbing FixturesPLUMBING PERMIAPPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
IProject M 26Pa
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Owner's Name _/ Last First MI
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Protect Atldres
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/(S1reBl 0 e _ Numpe`r n ; I /e /C �`
-11yyYY O`r/ h/ `
City ,
State
Subdivision/ Plat Name
Assessors Parcel 1
Lot
Block
Platt
Applicant
Address
City I State I Zip
Phone
Business Phone
Contractor. ---)Address
Je t_ LL—,t:_, r -,Ice. {�` � � -
? c`,l, ' c7 x /9l, 9/
City,
6/j717 kc_t,, i
State 11
.tis,
Zip
27.52G'
Phone
_5 7175 -G- 7l
Contact
License 1
Business Phone
Tttitl Ss 04 /19L -is
Describe Work
BarSink(s):
Drinking Fountain(s):
Floor Drain(s): /
Washing Machine(s): /
Dsh Wshr(s):
Garb Dlsp(s):
Kit Sink(s): 1
Lndry Tray(s): •
Sew Eject(s):
Urinal(s):
Wtr Closet(s):
Lav(s): ^'7
O��
Shower(s). /
Tub(s): /
Bidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer Y N Septic/ Health No.:
Electric Water Heater(s): /
1 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:
(005 +:
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 an other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
9
APPLICATION
DATE