1986, 09-02 Permit App: 00012967 Plumbing FixturesPLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
IProject # / 246,7
Owner's Name
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Project Address (Street Name & Number)
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City
State
Subdivision/Plat Name
Assessors Parcel #
Lot
Block
Plat #
Applicant
Address
City
I State
Zip
Phone
Business Phone
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Address
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CityState
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Zip
,ate
Phone
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Cont
License #
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Business Phone
Describe Work r 1 ,. l]
5 17:1 (LR-1%oi
Bar Sink(s):
Drinking Fountain(s):
Floor Drain (s): /
Washing Machine(s): it
Dsh Wshr(s): /
Garb Disp(s):
Kit Sink(s): /
Lndry Tray(s):
/
Sew Eject(s):
Urinal(s):
W1rCloset (s): 3
Lav(s): u
Shower(s): c
Tub(s): /
Bidet(s):
Other: Type; /7
Waste/Grease Interceptor(s):
Sewer Y N Septic/HealthNo.:
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 of a other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
APPLICATION /F4
DATE