1986, 07-11 Permit App: 00012117 Plumbing FixturesN
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_PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOS'`c PARTS OF THE FORM YOU UNDERSTAND
IProject /2 1 i 1
Owner's Name �_.....----- Lastu' First MI
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Project Address (Street a & Number)
4/ ASS/ u -c _,-, //
City
State
State
Subdivision/Plat Name
Assessors Parcel r/
Lot
Block
Plat It
Applicant
Address
City
I State
Zip
Phone
Business Phone
Contractor. ---)Address
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f?
?, 20x /9d -',S/
City
Zip
State -i pit_
Phone
Cont&
License t/
Business Phone
731-iN 1;111 // ,__J s
Describe Work / .2—
Bar Slnk(s):
Bar
Drinking Fountain (s):
Floor Dreln(s): /
Washing Machine(s):/
Csh Wshr(s):
Garb Dlap(s):
Klt Sinks) /
Lndry Tray(s):
Sew Eject(s):
Urinal(s)'
Wtr Closet (s):�
Lav(s): !J
v
Shower(s).
Tub(s): '0z
Bidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer ¥ N Septic/ Health No.:
Electric Water Heater(s): / 1
Drains -Roof:
REPAIR OR ALTERATION:Drainage, Vent, Water Piping/Treatment: V 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 provision, an other state of local laws regulating construction or the performance of
SIGNATURE OF
OWNER OR AGENT
APPLICATION 7/�r�%
construction.
.dam �S_ DATE