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1984, 08-21 Permit App: 00001947 Plumbing Fixtures• PLUMBING PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND 1 Owner's Name (Last) (First` (M) Zr p S ` \ i%1 Department Use Only Project No. 2 Project Address (Not Mailing Address) Space zip -3c /7 o c2 R �� 3 City/Community State Subdivision/Plat Name 4 Assessor Parcel No. I Lot Block 18 Contractor Firm Name Address 1Stree 1c. i Ck©Nc-cklo. ) �, t't %t t?(u r L1 1 17 Zip 9 920`1? - City own a kli--„e E State Lc)!�s A Phone (sag) '4/4r, -3i7?/ 18 Contact Pe - t License No. A,. -.%.� L Y k4 Phone If different than above .,�, e-- 8 Owner/Agent (if different than 81 above) Business Address 9 Zip City State Phone ( ) 15 Describe Work: New ❑ ; Addition/Alteration ❑ ; Replace/ Repair ❑ Total Number of Fixtures: 10 Applicant Name Street Address 11 Zip City State Phone ( ) 9 BarSink(s): Drinking Fountain (s): Floor Drain (s): Washing Machine(s): / 10 Dsh Wshr(a): Garb Disp(s): / Kit Sink(s): / Lndry Tray(s): Sew Eject (s): 11 Urinal(s): Wtr Closet (s): 3 Lav(s): Shower(s): Tub(s): Bidet(s): Other: Type; 12 Waste/Grease Interceptor(s): ..‘—.,/ o ^K4�S, /� ��J�J/ 13 Sewer Y Q 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+: 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 /v `G APPLICATION -`� aZ % 1� OWNER OR AGENT DATE