1985, 01-09 Permit App: 00003887 Plumbing FixturesrX
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First)
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Department Use Only
Project No.
2 Project Address (Not Mailing Address)
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Space
Zip
3 City/Community
ate
Subdivision/ Plat Name
4 Assessor Parcel No.
Lot
Block
16 Contrairm Name
Street Address
17 Zip
City
State
Phone
18 Contact Person
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Phone if different than above
8 Owner/Agent (if different than N1 above)
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Business Address
9 ZipCity
State
Phone
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15 Describe Work: New ❑ Addition I Alteration 21'
Replace/Repair ❑
Total Number
of Fixtures:
10 Applicant Name
Street Ad ress
11 Zip
City p�
State
Phone(
9 Bar Sink(s): /
TDrinking Fountain(s):
Floor Drain(s):
Washing Machine(s):
10 Deh Wshr(s):
Garb Disp(s):
Kit Sink(s):
Lndry Tray (s):
Sew Eject(s):
11 Urinai(s):
WtrCloset(s): /
Lav(s):
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:
17 Vacuum breakers or backflow devices in excess of line 16: 1-5:
(Or) 5+:
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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-
piled 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 APPLICATION _
OWNER OR AGENT CC�� ,DATE __
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