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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