1986, 03-11 Permit App: 00010027 Plumbing Fixturesy
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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1 Project M / e)2-7
Owner's Name Last First MI
(AJ RNS COnSt -
Project Address (Street Name & Number)
a3 o Z s. rnc&w\e1_
City
State
Subdivision/Plat Name
Assessors Parcel #
Lot
Block
Plat #
Applicant
Address
City
I State
Zip
Phone
Business Phone
Contractor SOK^ r� urka
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AtldresAr Or AJUx a6?/
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City
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State
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Zip
9?2a0
Sas- 0066
Goner
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BW'ness Phone
Describe Work /
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Bar SInk(s):
Drinking Fountaln(s):
Floor Drain(s): (
Washing Machine(s):
r
Lbh Wehrle): /
Garb Disp(s): /
Kit SInk(s): /
Lndry Tray(s):
Sew Elect(s):
Urinal(s):
Wt Closet(s): .3
Lay(s):
Shower(s): 1
Tub(s): (
Bidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer V N Septic/Health No.:
Electric Water Heater(s): /
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 16:1-5:
(Or) 5+:
7/
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.
OWNER OR AGENT DATE
SIGNATURE OF APPLICATION 3 _ ,
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