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1985, 06-11 Permit App: 00005855 Plumbing Fixtures
PLUMBING PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND ) 1' )( J Project # Owner's Name j Last Firs�t MI Project Address Street Name & Number) - 3 X02 - c 7'& City State Subdivision/Plat Name � Assessors Parcel # ������ Lot Block Plat # Applicant Address City r State Zip Phone Business Phone Address? © /V , A /3 / �7 /1 /7 - rector/ ;Ley() co 1 iV1�v✓1 Wil.-i1ti� City 6 State .4- Zip ?"2-0/ Phone 3,2.6-5 60 Contact ;1 License # ONITOPT' Aigcz- Business Phone Describe Work Bar Sink(a):t Drinking Fountain(s): Floor Drain (s): Washing Machine(s): l Doh Wshr(s): / Garb Disp(s): Kit Sink (s): f I Lndry Tray(s): Sew Eject (s): Urinal(s): WtrCloaet(s):V 2 Lav(s): 2 v Shower(s): Tub(s): ` Bidet(s): Other: Type; Waste/Grease Interceptor(s): Sewer Y N Septic/Health No.: Electric Water Heater(s): (mss . Drains -Roof: REPAIR OR ALTERATION: Drainage, Vent, Water Piping/Treatment: Y N Lawn Sprinkler System(s), including backflow device on any one meter: 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 APPLICATION OWNER OR AGENT DATE