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1986, 08-13 Permit App: 00012636 Plumbing FixturesW W cc 1- ccX 11 O W m 2 Z - PLUMBING PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND 1 Project « / 36 /24A Owner's Name Last First MI 1.-- zo4z/ =4,,� ; re w� r? o,v s Project Address (Street Name & Number) 3 _s.......0 4, S 7!'%%4'6 s rp City , t% S k_f4' dt..C. State Subdivision/Plat Name Assessors Parcelff Lot Block Plat # Applicant Address City I State Zip Phone Business Phone Contractor , 13 P k u, 0...(1 iAc)l Address (o ot'-1 o��ct\1.©c.3 City f�8l�i4-/td el' 1 State ! 44 C./ Zip ! ! 070 7 Phone "le 5' -34/-?/ 3L7/-?/ Conti 5 u.4.- License # w► t- A P 1, 15 v "-kb4 Business Phone ...4/4 r» 4 --- Describe Work /�Y ,e /4 '�j�/ / P / c...).i r'- tom! A 401-w6 / ^LI BarSink(s): Drinking Fouhteres): Floor Traih(SS): / Washing Machine(s): Doh Wahr(s): / Garb Dap (8): Kit Sink (s): / Lndry Tray (s): Sew Eject (s): Urinal (s): WtrCloset (s): 2 Lav(s): Z Shower(s): / Tub(s): / Bidet(s): Other: Type; Waste/Grease Interceptor(s): // /1"--/ X / _J it S - Sewer Y N Septic/Health No.: 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: (00 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 `ESL `C APPLICATION OWNER OR AGENT DATE '`g// 3At(r