1986, 03-27 Permit App: 00010220 Plumbing Fixturesf -
9o0
PLUMBING PERMIT APPLICATION SHEET
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
OWNER OR AGENT
APPLICATI9N
DATE 2? -8C,
.Project * f
Owner's Name Last First MI
Project Address (Street Name & Number) 3 YO � � p rG �CL
S_
City
State
Subdivision/Plat Name
Assessors Parcel *
Lot
Block
Plat #
Applicant
Address
City
I State
Zip
Phone
Business Phone
Contractor
Gam; 4J d/ 2
Address
/318 /Il- 4 ,�'. 4City
t/A-2
Sta
5190 �,4
Zip
�TZ0/
Phone
3z� -.5-600
Con
1
License *
uifiZ-TEAZ i.57 CS
Business Phone
Describe Work
Bar Sink (s):%
Drinking Fountain(s):
Floor Drain(s): /
Washing Machine(s):
Deh Wshr(s): /
Garb Dlsp(s):
Kit Sink(s): /
Lndry Tray (s):
Sew Eject (s):
Urinal(s):
WtrCloset (s):2
V
Lav(s): 3
Shower(s): ,,,Z
Tub(s): /'
Bidet(s):
ca
W
cr
Other: Type;
o
XWaste/Grease
Interceptor(s):
0
2
Sewer Y N Septic/Health No.:
W
D3
i
Electric Water Heater(s):
Drains -Roof:
D
Z
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:
(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
OWNER OR AGENT
APPLICATI9N
DATE 2? -8C,