1984, 07-09 Permit App: 00001186 Plumbing FixturesPLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) /(M)
Pr -r -r nib t ` / L
V 'V—
Department Use Only
Project No.
2 Project Address (Not Mailing A dress) Space Zip
87/1 &---, Th 4IN
3 City/Community 1
FIG (//t
State, 1
LW_
Subdivision/ Plat Name
4 Assesbor Parcel No
165'i1\ I
I Lot
Block
16 Contractor Firm Name
Owner`
Street Address
17 Zip
��z� z
City
o
State
uta
Phone
(c569) Tarbop
18 Contact Perspn
F red /4i 11-7 7—
1 License No.
Phone if different than above
8 Owner/Agent (If different than 41 above)
Busi ess Address
9 Zip
City
I State
Phone
15 Describe Work: New ❑ ; Addition/Alteration Replace/Repair ❑
Total Number
of Fixtures:
10 Applicant Name
Pre-; W, a (a.
I
Stree Address
57l4 , GI/• 1 frA
11 Zip
qg i?
City
Spn.
State
Wet
Phone
(509) i'2 -L( Gig 9
9 Bar Sink(s). .
I\
Drinking Fountaln(s):
Floor Drain (s):
Washing Machine(s).
yGarb
10 Dsh Wshr(s).
Dlsp(s):
Kit Sink(s)'
Lndry Tray(s):
/
Sew Eject(s):
11 Urinal (s):
Wt Closet(s): / '�(
Lav(s): ?ICI
Shower(s): y
Tubs).
Bidet(s).
Other: Type;
12 Waste/Grease Interceptor(s):
13 Sewer V / N� Septic/Health No.:
14 Electric Water Heater (s): YE
Drains -Root:
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:
(Or)54•
ce )c`( 2 Lf -I (0 = el, be,
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
c). iAtt -
APPLICATION
DATE 7- I- 8 Y