1986, 01-13 Permit App: 00009377 Plumbing Fixturesto
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
iProject # 3 77
Owner's Names Last f7 First MI
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Project Address Street a & Number)
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City State y
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Subdivision/ Plat Name
Assessors Parcel #
Lot
Block
Plat #
Applicant
Address
City
I State
Zip
Phone
Business Phone
Contract
Address
City
,--5-re kx-k, e
State
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Zip
R97.02. &
Phone
, 5 vas`' Z%e26 4
Contict License #
—150/1/ g PP /GLi--7-T--
Business Phone
Describe Work
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Bar Sink(s):
Drinking Fountain(s):
Floor Drain (s):
/
,
Washing Machine(s): /
Doh Wshr(s):
Garb Disp(s):
Kit Sink(s): /
Lndry Tray(s):
Sew Eject(s):
Urinal(s):
WtrCloset (s): _
Lav(s):
Shower(s): /
Tub(s): /
Bidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer Y N Septic/Health No.:
Electric Water Heater(s): !
Drains -Roof:
REPAIR OR ALTERATION: Drainage, Vent, Water Piping /Treatment: Y N
Lawn Sprinkler System(s), including backflow device on any one meter:
Vacuum breakers or backflow devices in excess of line 16:1-5:
(Or) 5+:
55 m
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 - • other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF DATE CATION l
OWNER OR AGENT /