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1985, 09-30 Permit App: 00007807 Plumbing Fixtures• PLUMBING PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND 1 Owner's Name (Last) �) (First) (M) / i�C, -1/-01a- ; Department Use Only Project No. 1 7 2 Project Address (POt ailing Address) Space Zip n 5, 072 V (62 11i Icy 3 City/Community 1I State Subdivision/Plat Name 4 Assessor Parcel 1 t' 1 Lot Block 16 Conor Firm Name © 7Addre8sJGt L',�r X ,`C"/ 17 Zip City SFr ketke-, State &,(", Phone ( ) 5 . -oma 18 Contact Person License No. Phone if different than above 8 Owner/Agent (if different than 41 above) Business Address 9 Zip City I State 1 Phone ( ) 15 Describe Work: New A; Addition/Alteration 0 ; Replace/Repair 0 Total Number /) of Fixtures: 10 Applicant Name Street Address 11 Zip City State Phone ( ) 9 BarSink(s): Drinking Fountain(s): Floor Drain (s): G Washing Machine(s): / 10 DO Wshr(s): Garb Disp(s): Kit Sink(s): / Lndry Tray(s): Sew Eject(s): 11 Urinal(s): WtrCloset(s): 2` ,;..1.‘ Lav(s): Shower(s): ` ( Tub(s): / I Bidet(s): l 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 any other state of local laws regulating construction or the performance of construction. SIGNATURE OF OWNER OR AGENT DATE APPL- ICATION 2)4_ /