1986, 05-08 Permit App: 00011061 Plumbing Fixtures•t-.
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
I Project
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Owner's Name Last First MI
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Project Addr (Street NA & Number)
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City State
Subdivision/Plat Name
Assessors Parcel it
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Lot
Block
Plat a
Applicant
Address
City
I State
Zip
Phone
Business Phone
Contr
Add
City ,��
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Zip
19970?0
Phone
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Contact
License a
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Business Phone
Describe Work �
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Bar Sink(s):
Drinking Fountain(s):
Floor Drain(s): /
'
Washing Machine(s): /
Oeh Wshr(s):
Garb Dlsp(s):
Kit Sink(s): /
/
Lndry Tray(s):
Sew Elect(s):
Urinal(s):
Wt Closet(s): /7._
Lav(s): y`
Shower(s): 1
Tub(s): /
Bidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer V 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 18:1-5:
(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 provision . any r her state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT'
APPLICATION
DATE r ,�lj