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1986, 01-16 Permit App: 00009442 Plumbing FixturesPLUMBING PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND 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 ' •t. The granting of a permit does not presume to give authority to violate or cancel the provisio er state of local laws regulating construction or the performance of construction. SIGNATURE OF OWNER OR AGENT APPLICATION / DATE Project # Q-#.1t.g..._ RES Owner's Name Last ....------ First MI Project Address (Street Name 8 1u ber) - E,I 765 /ytt /L City State 7 Subdivision/ Plat Name Assessors Parcel # Lot Block Plat # Applicant Address City I State Zip Phone Business Phone Contras �/ ©� V� ����C�e�% P± 14 Address / Pei City 1 State o .�� (1 A-2(27�u Zip Phone _ �Q6� Contact Illgepse4/f / n- A[ Rf P /5�, Phone Describe Work 5---! G --) x �-I. I—c� Bar Sink(s): Drinking Fountain(s): Floor Drain (s): l Washing Machinets7: Dsh Wehr(s): Garb Disp(s): Kit Sink(s): 7 Lndry Tray(s): Sew Eject (s): Urinal (s): Wtr Closet (s): 1---Lav(s): �"_— Shower(s): f L Tub(s): / Bidet(a): Other: Type; 5 X Waste/Grease Interceptor(s): LI- O CC Sewer Y N Septic/Health No.: W CO Electric Water Heater(s):l Drains -Roof: D Z 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: (005+ : 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 ' •t. The granting of a permit does not presume to give authority to violate or cancel the provisio er state of local laws regulating construction or the performance of construction. SIGNATURE OF OWNER OR AGENT APPLICATION / DATE