1986, 01-02 Permit App: 00009323 Plumbing FixturesPLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) (M)
Department Use Only
Vi&C if y/ ^� ; r& "-
Project No. 1 4�
2 Protect Address (Not Mailing Address) Space Zip
2S 17 S 40 te144
3 City/Community
I State
L
Subdivision/Plat NameA
mid f/ G
4 Assessor Parcel No.
Lot
Block
16 Contractor Firm NameStreet
44.({r="tVc E'I(hcb.
Address
nnX 223
17 Zip
9 a S
ity
N t.�� ha &
State
t,�,�q. -
Phone a
(o ('�G) OSS'
18 Contact Person (� License No.
)1`,_,_ Sull( 4Alt �p fesdz
Phone if different than above
8 Owner/Agent (if different than #1 above)
.
Business
Address ___ -
9 Zip
City
State
Phone
( )
15 Describe Work: Newt; Addition/Alteration ❑ ; Replace/Repair ❑
Total Number 0
of Fixtures:
10 Applicant NameStreet
t64.4.4/ � jLGfIyE
Address
11 Zip
City
State
Phone
1 )
9 Bar Sink(s):
, Drinking Fountain(s):
Floor Drain (s):
Washing Machine(s): /
10 Dsh Wshr(s):
Garb Disp(s):
Kit Sink(s): /
Lndry Tray(s):
Sew Eject(s):
11 Urinal(s):
WtrCloset(s):
Lav(s): 3 1
Shower(s): z l
Tub(s): /
1 Bidet(s):
Other: Type;
12 Waste/GreaseeaInterceptor(s):
13 Sewer �r N Septic/Health No,:
14 Electric Water Heater(s):
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:
(005 + :
Nlr z = 4 $ f iv S'$
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
tUe6:—
APPLICATION ��yy
DATE /"� v�