1985, 01-21 Permit App: 00003977 Plumbing Fixutres•
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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 Owner's Name (Last) 's
Department Use Only
IV K , j y�(FFlr�st) f /
f��C� N/�/ e �� 4Project
No.
Space i g v `lam
.53M 2 Project Aresa (Notailing' ) L I SS iq 02,
3 City/Community
I State
Subdivision/Plat Name
4 Assessor Parcel No.
Lot
1
Block
3gl79
16 Contractor Firm Name
Street Address
17 Zip
City
State
Phone
( )
18 Contact Person
I License No.
Phone if different than above
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
State
Phone
( )
15 Describe Work: New 0 ; Addition I Alteration 0 ; Replace/Repair ❑
Total Number
of Fixtures: �/
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
9 BarSink(s):
Drinking Fountain(8):
Floor Drain (s):
Washing Machine(s): '
10 Dah Wshr(s): I
Garb Disp(s):
Kit Sink (s):
Lndry Tray (s):
Sew Eject (s):
11 Urinal(s):
—
WtrCloset(s):
Lav(s):
I/
I t Shower(s): I
I Tub(s): C
I Bidet(s):
Other: Type;
12 Waste/Grease Interceptor(s):
13 Sewer Y N Septic/HealthNo,:
14 Electric Water Heater(s):1
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:
(005 +:
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 oar state of local laws regulating construction or the performance of
construction.
SIGNATURE
OWNER 0
•
APPLICATION
APPLICATION /
'__,„v't:::7 DATE ! U