1985, 01-24 Permit App: 00004043 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)
it►A L et MF . M 1(Adve.1
Department Use Only
Project No.
2 Project Address (Not Mailing A dress) Space Zip
3 City/Community
tate
.t....60,
Subdivision/Plat Name
Ali b(/o-.,1t'
4 Assessor Parcel No.
Lot
1
Block
'Xi)51.
16 Contractor Firm Name
4 t,,vL i. (�.j
Street drea��� Z
17 Zip
C a J a
CfCity�.�.
��4✓i��:0.) kiC
State
tt.i6 -
Phone
(ZZ() 6 f7 j'
18 Contact Pe o
SciL����
License No.
JJ ,��
Phone if different than above
8 Owner/Agent (if different than 41 above)
Business Address
9 Zip
City
State 1 Phone
( )
15 Describe Work: New t Addition/Alteration ❑ ; Replace/Repair ❑
Total Number ��
of Fixtures:
10 Applicant NamStreet
-LL1-LVi)11
Address
ZipJ.>rVJ
City
State
Phone
( )
9 BarSink(s):
is
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): 3
Lav(s): ?
�7
Shower(s): t 1
Tub(s): /
Bidet(s):
Other: Type;
12 Waste/Grease Interceptor(s):
13 Sewer 6 N Septic/Health No.:
Drains -Roof:
14 Electric Water Heater(s): r
15 REPAIR OR ALTERATION: Drainage, Vent, Water Piping /Treatment: Y N
16 Lawn Sprinkler System(8), including backflow device on any one meter:
17 Vacuum breakers or backflow devices in excess of line 16:1-5:
(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
DATE
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