1984, 08-03 Permit App: 00001580 Plumbing Fixturesrn
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1
Owner's Name (Last) (First)
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(M)
Department Use Only
Project No.
2
Project Address (Not Mailing Address)
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Space
Zip
3
City/Community
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Subdivision/ Plat Name j
I�C At 6( A(
4
Assessor Parcel)No.
Lot
Block
16 Contractor Firm Name %
Street Address
17
Zip
Q
City
�QA(s-
State
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)/Phone 2a
49Z(`2?73
18 Contact Person
License No.
Phone if different than above
8 Owner/Agent if different than N1 above) %
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Business Address
9
Zip
City
State
Phone
15
Describe Work: New; Addition/Alteration ❑
Replace/Repair ❑
Total Number
of Fixture .
10 Applicant Name
Street Address 141--
11
Zip
City
State
Phone
9
Bar Sink (s):
Drinking Fountain(s):
Floor Drain (s):
Washing Machine(s):
10
Dsh Wshr(s): A
Garb Disp(s)):,
Kit Sink(s):
f
Lndry Tray(s): !
Sew Eject(s):
11
Urinal(s):
WtrCloset(s): (
y'
Lav(s):
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+:
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 loca laws regulating construction or the performance of
construction.
SIGNATURE OF �' __ APPLICATION g
OWNER OR AGENT --gym_ DATE �J