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1986, 11-12 Permit App: 00014090 Plumbing Fixturesur W cc tL LL ccO co 0 i z Z r PLUMBING PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND AS 1 Project', 14loga 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 , ,-,,-, ..-t/'rstiiftz- Subdivisl n/Plat Name b!e t 4J Oto 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+ : a) .K C(z I z -'f- 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