1986, 05-06 Permit App: 00011062 Plumbing FixturesPLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY -THOSE PARTS OF THE FORM YOU UNDERSTAND
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Owner's NameLast First MI
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Project Address ( treet ml & Numbe) •
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City
State
Subdivision/Plat Name
Assessors Parcel 4
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Lot
Block
Plat
Applicant
Address
City
I State
Zip
Phone
Business Phone
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Address
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City,State
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Zip
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Phone
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Cont
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Business Phone
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Describe Work
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Bar Sink(s):
Drinking Fountain jap
Floor Drain (s): 1
Washing Machine(s):
De Wshr(s):
Garb Disp(s):
Kit Sink(s)' /
Lndry Tray (s):
Sew Eject(s):
Urinal (s):
Wt Closet (s).
Lay(s): CI
Shower(s): / J
Tub(s): /
Bidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer Y N Septic/Health No.:
Electric Water Heater(s): /
Drains -Root
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 provision .1 any other state of local laws regulating construction or the performance of
construction. �
SIGNATURE OF
OWNER OR AGENT
APPLICATION
DATE