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1985, 09-04 Permit App: 00007224 Plumbing Fixutres
PLUMBING PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND IProject # z_z_tk RES Owner's Name Last \/* First j� MI pr9iect Aey rash & N17)01 ii2n17� it State Subdivision/Plat Name Assessors Parcel# Lot Block Plat # Appli t1 ' ill AD1S<— Address cF©• EV)(" -'3 jy t7 RADA `i I Stateo A S /'Y e Zip/ / 0 ,� / Phone 47i_ 6. ^ 7 1 Business Phone Contractor -541Zt L Address City ( State Zip Phone Contact License # ECS-(C.f 26;9`C n'1 Business Phone Describe Work /� > / ,7J /3p/ g (o Bar Sink(s): ((( Drinking Fountain (s): Floor Drain(s): / Washing Machine(s): Doh Wshr(s): Garb Disp(s): Kit SInk(s): Lndry/Tray (s): Sew Eject(s): Urinal(s): Wtr Closet (s): Lav(s): �1� p Shower(s): / Tub(s): / Bidet(s): Other: Type; 65 XWaste/Grease Interceptor(s): LL II- O CCW Sewer Y N Septic/Health No.: _CO Electric Water Heater(s): f Drains -Roof: D Z 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 Zine 16:1-5: (Or) 5 + : /o 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 (�^ Q OWNER OR AGENT 4`i �—^ '� APPLICATION DATE ,1/5C-