1984, 11-26 Permit App: 00003477 Plumbing Fixturesw
NUMBER OF FIXTURES
PLUMBING PERMIT APPLICATION WORKSHEET
'4EASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name)
2 Project Address ( t Mailing Address)
/If3 /3' -"?
L.., First)
(M)
Department Use Only 3417
Project No,
Space Zip
3 City/Community I State
Subdivision/ Plat Name
4 Assessor Parcel No.
Lot
Block
18 Contract rm
Street Address
Cc3, 3
Cit
18Person I license No.
i0` ---I bo CO 5-v a%Cv-
17 ZIP �9,?.‘ SP
State
Phone
Phone if different than above
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
State
Phone
( )
15 Describe Work: New gc .
Addition/Alteration ❑ ; Replace/Repair ❑
Total Number
of Fixtures:
10 Applicant Name
Street Address
11 Zip
9 Bar SInk(s):
10 Dsh Wshr(s):
City
Drinking Fountaln(s):
Garb DIsp(s):
Kit Sink(s):
State
Floor Drain(s):
Z
Phone
( )
Lndry Tray(s):
Washing Machine(s):
Sew Eject(s):
11 Urinal(s):
Wtr Closet (s):
Lav(s): L,/
Shower(s):
Tub(s):
Bidet (s):
Other: Type;
12 Waste/Grease Interceptor(s):
13 Sewer Y N Septic/ Health No.:
14 Electric Water Heater(s):
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:
1
17 Vacuum breakers or backflow devices In excess of line 16: 1-5:
(00 5+:
�d
I certify that the above information as submitted by me is true and correct and further, gree 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 agy_pther state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
APPLICATION
DATE 1 j o9-4'15