1986, 04-09 Permit App: 00010445 Plumbing FixturesPLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last)//n (First) (M)
Department Use Only _
Mt Chr d i £o e
Project No. `C./4/j
2 Project Address (Not Mailing Address) Space Zip
3 City Commu ity
5/0 d ctiv C
State
(. -q ti 4
Subdivision/Plat Name
4 Assessor/Parcel No.
ILot
Block
16 Contractor Firm Na a
r T.6 r ,-e-v-, v t ) es .1-a.1 C
Street Address
/14,07 £ 7-ve&J-
17 ZCity
I99°j20'le Ze-gr ie
State
(.1-0S!-
Phone
1 ) %??"-Pti9Z
18 Contact Person
/1
License No.
. i71-BE-N---273RL
Phone if different than above
7 e 0P e# -zt -
8 Owner/Agent (if different than 011 above)
Business Address
9 Zip
City
I State
Phone
( )
15 Describe Work: New IC‹, Addition/Alteration 0 ; Replace/Repair ❑
1�
Total Number ♦) _
of Fixtures: l///
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 Disp(s):
Kit Sink(s)' l
Lndry Tray(s). /
Sew Eject (s):
11 Urinalis).
Wt Closet(s):
Lavish 3
I Shower(s)' /
Tub(s):
/
Bidet(s)'
Other. Type;
12 Waste/Grease Interceptor(s): /
13 Sewer Y N Septic/Health No.'
tO
14 Electric Water Heater(s): /� --/C1--5
Drains -Roof
15 REPAIR OR ALTERATION: Drainage, Vent, Water Piping/Treatment: Y N
16 Lawn Sprinkler System(s), including backflow device on any one meter:
17 Vacuum breakers or backflow devices in excess of line 16:1-5:
I (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 sta_of local laws regulating construction or the performance of
construction.
SIGNATURE OF �����— APPLICATION �,e/ p�/
OWNER OR AGENT� ' DATE ( ?/ �J Jv
44°c
(SSS'
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