1986, 07-07 Permit App: 00011371 Plumbing FixturesPLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
IProject * 1 r 07 /
Owner's Name Last First MI
Com. v. en a-4. 19-e h n /r 'Al,.
Project Address (Street Name & Number)
-S- S, -f'/ a ! i 9 e -/4.7-r GL
(ity
Sc'JO k o... h .e
State ' /
(A/ c,,r %1 '
Subdivision/Plat Name
Assessors Parcel #
Lot
Block
Plat #
Applicant
C/4tgiinArv.1 Qr�
I.17Y P/�G
Address
ti .aO /.2 -/ e Al
City
5000 0 kc„.h
State
li✓C.ttX •
Zip
97 2/ 2
Phone
9 2 (/-3/ 2G'
Business Phone
�asi,-Q-
Contractor
Address
City
I State
Zip
Phone
Contact
License #
G/IRritiGP/Y3J'T
Business Phone
Describe Work
Bar Sink(s):
Drinking Fountain(s):
Floor Drain (s):
Washing Machine(s): /
Deh Wshr(s): /
Garb Diap(s): /
Kit Sink (s): /
Lndry
Tray(s): /
Sew Eject(s):
Urinal(s):
Wtr Closet (8):
Lav(s): (J
J
Shower(s):
Tub(s): e2
Bidet(s):
N
W
CC
Other: Type;
D
XWaste/Grease
Interceptor(s):
O
CC
Sewer Y N Septic/ Health No.:
W
CO
2
Electric Water Heater(s): /
/
Drains -Roof:
D
Z
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 any other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF �)
OWNER OR AGENT
APPLICATION
DATE 7/7�F'