1985, 04-16 Permit App: 00004954 Plumbing Fixtures•
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
•
- 1 Owner's Nameit Last) (Fast) (M)
Department Use Only
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:' kn/S Pi 12n to a -//L ) L `4o /.../-
Project No
2 Project Address (Not Marling Address) Space Zip
C. /?7/ /Via HTPv ed,
3 City/Commmunnpity kStale
O {1 t(1 -;I
Subdivision/ Plat Name
4 Assessor Pace! No.
Lot
lock4/(1-5
/�5
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S16
Contractor Firm Name
Street Address
17 Zip
I City
State
Phone
( )
18 Contact Person
I License No.
Phone if different than above
8 Owner/Agent (11 different than 41 above)
Business Address
9 Zip
City
I State
Phone ,
( )
15 Describe Work: New 0 ; Addition/Alteration 0 ; Replace/Repair ❑
Total Number
of Fixtures:
10 Applicant Name
Street Address
11 Zip
City •
State
Phone
( )
9 Bar Sink(s)'
Drinking Fountain(s):
Floor Drain (s).
Washing Machine(s).
10 Dsh Wshr(s):
Garb ()lapis):
Kit Sink(s):
Lndry Tray(s)
Sew Eject (s)40, /
11 Urinal(s).
Wt Closet(s): /
Leyte): /
Showerls):
l Tub(s)e'
/
Bidet(sp
Other Type;
12 Waste/Grease Interceptor(s):
13 Sewer V N Septic/Health No.:
14 Electric Water Heater(s):
Drains -Roof
15 REPAIR OR ALTERATION: Drainage, Vent, Water Piping/Treatment: V N
16 Lawn Sprinkler System(s), including backflow device an any one meter'
17 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 any other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
APPLICATION
OWNER OR AGENT DATE