1984, 08-28 Permit App: 00001975 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 Name (Last) (First) (M)
�,(e
I Department Use Only
/`'��
Project No.
I
2 Project Address (Not Mailing Addr ,!�( Space Zip
330
3 City/Community
I State
Subdivision/ Plat Name
4 Assessor Parcel o.
Lot
Block
16 Contr r Firm ame /, (�
_,__
Stree
Address
00.1-G2 ,3 E �-
17 Zip
f�/�.
City
State
Phone
18 Con roon
�(�0�
License No.
44:00 Nod 5041 a� ��
Phone if different than above
8 Owner/Agent (if different than #1 above)
Business
Address
9 Zip
City
State
Phone
( )
15 Describe Work: New- Addition/Alteration 0 ; Replace/ Repair ❑
Total Number
of Fixtures:
10 Applicant Name -
Street Address
11 Zip
City
State
Phone
( )
9 BarSink(s):
Drinking Fountain (s):
Floor Drain (s): t
Washing Machine(s):
(
10 Dsh Wshr(s):
Garb Disp(s):
Kit Sink(s): I
Lndry Tray(s):
Sew Eject(s):
11 Urinal(s):
WtrCloset (s):
Lav(s): 5.
1 Shower(s): 1
1 Tub(s):
/
Bidet (s):
Other: Type;
12 Waste/Grease Interceptor(s):
13 Sewer Y N Septic/Health No.:
14 Electric Water Heater(s):
(
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:
(00 5+ :
kilet
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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
OWNER OR AGENT
APPLICATION e r 6142
DATE