1985, 03-01 Permit App: 00004349 Plumbing Fixtures•
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Named patj t) (M)
"/stk
[]apartment Use Only
Project No.
2 Project Address (Not Mailing Address) Space Zip
Say 3tt 4-oQe
3 City/Community
State
Subdivision/Plat Name
4 Assessor Parcel No.
1 Lot
Bloc
1M/�
16 Contractor Firm Name
Street Ad ,.. cp
17 Zip
CisV /�� �"c/ kt
"State
"`
Phone /�
(2. /� 0(l/q sS
18 Contact Pe --
I License No.
tetoro
Phone if different than above
8 Owner/Agan f different than 81 above)
Business Address
9 Zip
City
State
Phone
( )
15 Describe Work: New )cr; Addition/Alteration 0 ; Replace/Repair ❑
Total Number
of Fixtures:
10 Applicant Name
1.s
v r& ECL. I4 _
Street Address
PoK.e. A -S c b v
11 Zip
City
State
Phone
( )
9 Bar Sink(s):
Drinking Fountain(s):
Floor Drain (s): /
Washing Machine(s): /
10 DM Wshr(s):
Garb Disp(s):
Kit Sink(s): /
Lndry Tray(s):
Sew Eject(s):
11 Urinal(s):
WtrCloset(s): 3
Lav(s): 3
Shower(s): Z
I Tub(s): 1 I
Bidet(s):
Other: Type;
12 Waste/Grease Interceptor(s):
13 Sewer N Septic/HealthNo.:
14- ElectrlrWater-Heaterrs)c i
—Drains -Roof:
15 REPAIR OR ALTERATION: Drainage, Vent, Water Piping /Treatment: Y N
16 Lawn Sprinkler System(s), including backflow device on any one meter:
17 Vacuum breakers or backflow devices in excess of line 16:1-5:
1
(00 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
APPLICATION 3
DATE _ /