1985, 05-28 Permit App: 00005701 Plumbing Fixutres•
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PLUMBING PERMIT APPLICATION WORKSHEET S S -Q'
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Nang.. (Last)_` (First) (M)
/ Lfi ppe._I/ d.__Ai a
Department Use Only
Project No.
2 Project Address (ot 11Aailing Address) Space Zip
. /40 . 0/,i.c.- f ,G__---
3 City/Community
I State
Subdivision/Plat Name
4 Assessor Parcel No.
Lot
Block
16 Cont DL U�m Name t C_t''>S FN
Street Address ax. -747/
T(�/Y{Phlone
17 Zip
City
State
ze)et,..
18 Contact Person y
.
License No.
44ygp,/ /14.1,1.1
Phone if different than above
8 Owner/Agent (if different than 41 above)
Business Address
9 Zip
City
State
Phone
( )
15 Describe Work: New Addition/Alteration ; Replace/Repair ❑
' ! 17
Total Number
of Fixtures:
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
9 Bar Sink(s):
Drinking Fountain(s):
Floor Drain (s): /
Washing Machine(s): /
10 Doh Wshr(s):
Garb Disp(s):
Kit Sink(s): /
Lndry Tray(s):
Sew Eject(,):
11 urinal(,):
WtrCloset (s):L
Lav(s): 1/43
I Shower(s):
I Tub(s)::
Bidet(s):
Other: Type;
12 Waste/Grease Interceptor(s):
13 Sewer Y N Septic/ Health No.:
14 Electric Water Heater(,): /
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:
(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 not. The granting of a permit does not presume to give authority to
violate or cancel the provisions o an other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
APPLICATION
DATE d7o/�