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1984, 08-08 Permit App: 00001667 Plumbing Fixturesw PLUMBING PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND 1 Owner's Name (Last) first) (M) LL"�S Com/ Department Use Only Project No. 2 Project Address (Not Mailing Address) �Space Zip A102— V _iWU_e_N 3 City/Community State Subdivision/ Plat Name 4 Assessor Parcel No. Lot Block tractor Firm Name r Street Address 17 Zip City �/b�•��t State Gam- Phone �o�) ��4<<3sF�3 18Co9j4gPerson r'K , 1-� t �o� License No. C© �-a 4 a 110 C Phone if different than above 8 Owner/ Agent (if different than N1 above) Business Address 9 Zip City State Phone 15 Describe Work: New 19'— Addition/Alteration ❑ Replace/Repair ❑ Total Number of Fixtures: 10 Applicant Name Street Address 11 ZIP Ti"__ State Phone 9 Bar Sink(s): Drinking Fountaln(s): Floor Drain (s): Washing Machine(s): / 10 Dsh Wshr(s): Garb Disp(s): Kit Sink(s): r Lndry Tray (s): Sew Eject (s): / 11 Urinal(s): WtrCloset(s): 3 Lav(s): �oe Shower(s): Z Tub(s): / Bidet (s): Other: Type; 12 Waste/Grease Interceptor(s): 13 Sewer Y N Septic/ Health No.: 14 Electric Water Heater (a): / Drains -Roof: 15 REPAIR OR ALTERATION: Drainage, Vent, Water Piping /Treatment: Y N 18 Lawn Sprinkler System (a), including backflow device on any one meter: 17 Vacuum breakers or backflow devices in excess of line 18: 1-5: �� • Y 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 APPLICATIO OWNER OR AGENT I Xt�� DATE -B -S