1986, 09-22 Permit App: 00013511 Plumbing FixturesW
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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Owner's Name p Last First MI
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Project Address (Street Name & umber)/i5 v2 '/^,612—f j
City
State
Subdivision/Plat Name
Assessors Parcel N
Lot
Block
Plat ll
Applicant
Address
City
I State I Zip
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Phone
Business Phone
Contractor
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Address
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City
I State - i� �Zlp
Phone
Contaft
License N
Business Phone
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Describe Work g r i / X cc.izfits
Bar Sink(s):
Drinking Fountain(s):
Floor Drain s)• �J
Washing Machine(s): —7
Dsh Wshr(s):
Garb Disp(s):
Kit Sink(s):
LnddryCTray(s)
Sew Elect(s):
Urinal(s):
Wtr Closet(s): a
Lav(s). 2
Shower(s): 02.
Tub(s):
Bidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer V N Septic/Health No.:
Electric Water Heater(s): / I Drains -Roof:
REPAIR OR ALTERATION: Drainage, Vent, Water Piping/Treatment: V N
Lawn Sprinkler System(s), Including backflow device on any one meter:
Vacuum breakers or backflow devices In excess of line 16:11-S:
(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 provisioytstof q,gy other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
APPLICATION�
DATE 723.2,/�/