1986, 03-03 Permit App: 00009891 Plumbing Fixturesw
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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 ny=o er state of local la s regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
DATE CATION `�7�/��
Project p c/ Cv /
Owner's Name/11 Last First MI
I/ p
('1- �A71-r re r a st S
Project Address (Street Name & Number)
r, 149X4,2 jot 142
City
State
Subdivision/Plat Name
Assessors Parcel a
Lot
Block
Plat If
Applicant
Address
City
I State
Zip
Phone
Business Phone
tecter
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Addreyy(J,
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26/ _249- /
City c) r��.tJ r -
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State 1�
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Zip
91 QD
Phone�/J5�� 5 '&44:
Cant
Licen • 'Business
)14 NgP!/ // ySD
Phone
Describe Work /
/ / X 4te re; g7
Bar Sink(s):
Drinking Fountain(,):
Floororaln(s): /
Washing Machine(s): /
an Wshr(s): /
Garb Diep(s):
Kit Sink(s): /
Lndry Tray(s).
Sew Eject(s):
Urinal(s):
WI Closet(s): .
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Lav(s):
Shower(s): /
Tub(s): /
Bidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer Y N Septic/Health No.:
Electric Water Heater(,): /
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:
(Or) 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 ny=o er state of local la s regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
DATE CATION `�7�/��