1986, 07-24 Permit App: 00012950 Plumbing Fixturesy `t
PLUMBING PERMIT APPLICATION WORKSHEET
4RINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
3 X G 52. 4 19 - (7"
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 2 Y A-�
OWNER OR AGENT DATE /c/
Project N
S7Name Last
First
MI
m-rs
Project Address (Street Name & Number)
s i4(o?
"Alokt-�
City
State
Subdivision/ Plat Name
Assessors Parcel
Lot
Block
2-
Plat If
Applicant� / I /
Address
Y 2G
dt, c
City� �
State
Zip
Phone
Business Phone
S 'o
Contractor�£� S�/'°`-t
Ci .+� G
Address
/y G
City
State State
Zip
Phone
Contact
License N
Business Phone
Describe Work
Bar Sink(s):
Drinking Fountain(s):
Floor Drain (a):
/
Washing Machine(s):
Dah Wehrle):
___
Garb Disp(s):
Tt Sink(s):
/
Lndry Tray (a):
Sew Eject(s):
Urinal(a):
Wtr Closet (a): 3
Levis): 3
Shower(s): /
Tub(s):
J
W
Other: Type;
n
XWaste/Grease
Interceptor(s):
LL
W
0
Sewer Y N Septic/ Health NO.:
IX
W
M
Electric Water Hester(s): ✓
Drains -Roof:
Z
REPAIR OR ALTERATION: Drainage, Vent, Water Piping /Treatment: Y N
Lawn Sprinkler System is), including backflow device on any one meter:
Vacuum breakers or backflow devices in excess of line IS: 1-5:
(Or) 5+:
3 X G 52. 4 19 - (7"
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 2 Y A-�
OWNER OR AGENT DATE /c/