1986, 08-08 Permit App: 00012558 Plumbing Fixturesco
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
IProject # I2
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Owner's Name
Last First MI
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Project Address (Street Name & Number)
34 5 g_,1 t sa-
City
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State (-•.Jel
Subdivlsl nq / Plat L 101/ e/ `L- -
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Assessors Parcel #
Lot 7
Block /
Plat #
Applicant
Address `l�J \ ��I �.0), (24 1 ' L
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City I
State
Zip
Phone
Business Phone
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Contractor/ �_-- `/ _...1-„t`i LYS�U l
Addr�a-�� Pok,/24 /
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State' / J
Zip / �f/
Phone
Contact
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License #
C --z r S iSs'o
Business Phone
7 3 q?
Describe W
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Bar Sink(s):
Drinking Fountain(s):
Floor Drain(s):
Washing Machine(s): 1
Deh Wshr(s): /
Garb Diep(s):1
Kit Sink(s): /
Lndry Tray(s):
Sew Eject(s):
Urinal(s):
Wtr Closet (s): 7.,
Lav(s): 7i
Shower(s): /
Tub(s): /
Bidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer 5 N Septic/Health No.:
Electric Water Heater(s): 93,
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 18:1-5:
(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 any other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
APPLICATION 5...e 66
DATE