1985, 09-17 Permit App: 00007636 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)Department
-
„f r 1 A e f
�ress�p
Use Only �(
Project No. 7 3�
2 Project gt Mailing Address) Space Zip
E. t 4 t 7 city Ft -L aye--%
. 3 City/Community /
I State
Subdivision/Plat Name
7) 4 Assessor Parcel No.� ��
1 Lot
Block
18 Con r(actor Firm Name n [�
St
t Address
17 Zip
en
City
State
Phone _
18 Contact Person i)
License No. / 7‘,2-171-
AFL- GtiLtL �P11
Phone if different than above
—
8 Owner/Agent (if different than 01 above)
Business
Address
9 Zip
City
1
I State
Phone
( )
15 Describe Work: New F; Addition/Alteration ❑ ; Replace/Repair n
Total Number
of Fixtures:
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
9 BarSink(s):
Drinking Fountain(s):
Floor Drain (s): /
Washing Machine(s):
10 Ceh Wshr(s):
Garb Disp(s):
Kit Sink(s): /
Lndry Tray(s):
Sew Eject(s):
11 Urinal(s):
WtrCloset(s):
Lav(s): %
I
I Shower(s): (
1
I Tub(s): (
l
Bidet(s):
Other: Type;
12 Waste/Grease Interceptor(s):
13 Sewer Y N Septic/Health No.:
14 Electric Water Heater(s): (r
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:
(00 5+:
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 APPLICATION 9/g7h,
OWNER OR AGENT /IAA (�� �> DATE