1986, 11-12 Permit App: 00014090 Plumbing Fixturesur
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
AS
1 Project',
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Owner's Name Last First MI
Re//cR D -'x2' .D
Project Address (Street Name S. Number)
2 -9 -Sit / -,-Pr //%a7, i.J
City
sPo�%� ro
State
, ,-,,-,
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Subdivisl n/Plat Name
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Assessors Parcel It
/55 - 22o.6
Lot
3
Block 2
49. -
Plat M
Applicant
DJz l Ro/%J2
Add ass
zC 3,-err-Aio',,''
City
410
State
G✓a,Sl, .
Zip
9"%/1' /
Phone
nyr 91,'L V-Y7QC,
..-6-274/<'0:
Business Phone
Contractor
Address
City
I State
Zip
Phone
Contact
License p
Business Phone
Describe Work
cl K 11.4..2-cs
Bar Sink(s):
Drinking Fountain(s):
Floor Drain(s):
Washing Machine(s):
CM Wshr(s):
Garb Disp(s):
Kit Sink(s):
Lndry Tray(s):
Sew Eject(s):
Urinal (a):
Wt Closet (s): /
Lav(s): /
Shower(s): /
Tub(s):
Bidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer N Septic/Health No
Electric Water Heater(s):
Drains -Roof:
REPAIR OR ALTERATION: Drainage, Vent, Water Piping / Treatment • 0 N
Lawn Sprinkler System(s), Including backflow device on any one meter:
Vacuum breakers or backflow devices In excess of Iine 16:1-5:
(005+ :
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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 DATE
APPLICATION