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1985, 09-17 Permit App: 00007637 Plumbing Fixtures• PLUMBING PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND 1 Owner's Names (Last)(First) (M) G t".. -f �e + 7 Department Use Only -�J Project No. /6.5 7 2 Project Address Not Mail Address) Space Zip . 1gt23 6t�zi<`t_P �� 3 City/Community IState Subdivision/ Plat Name 4 Assessor Parcel No. (7t//) Lot I Block _ 16 Contractor Firm Name _J9a L 14.. 2,_,. r k r4- Street Address Vic, 13 cri X'-2---c---it 17 Zip City 1 State Phone 18 Contact Person License No. iw gft/ /62\75D--- 6, .'Jy8 Phone if different than above 8Owner/Agent (if different than 41 above) Business Address ' 9 Zip City 1 State Phone ( ) 15 Describe Work: New J El; Addition/Alteration ❑ ; Replace/Repair Total Number I j 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 Dsh Wshr(s): Garb Disp(s): Kit Sink(s): / Lndry Tray(s): Sew Eject(s): 11 Urinal(s): Wtr Closet (s): 1 Lav(s): i Shower(s): / Tub(s): / / Bidet(s): Other: Type; 12 Waste/Grease Interceptor(s): 13 Sewer Y N Septic/Health No.: 14 Electric Water Heater(s): ` 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: (Or) 5+: 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 OWNER OR AGENT APPLICATION 0 DATE / /2;43