1986, 01-23 Permit App: 00009495 Plumbing Fixtures•
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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Project Address (St ree Name Number)
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City
State
Subdivision/Plat Name
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Lot
Block
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Applicant
Address
City
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Zip
Phone
Business Phone
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Business Phone
Describe Work
12 Ir1xI(c/re`s
Bar Sink(s):
Drinking Fountain(s):
Floor Drain(s):
Washing Machine(s): /
DM Wshr(s): L
Garb Dlep(s):
Kit Sink(s): /
Lndry Tray(s):
Sew Eject(s):
Urinal(s):
Wt Closet (s): -
Lay(s):,�J
'7
Shower(s): I
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: 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 ny other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
APPLICATION //73 A
DATE oc