HomeMy WebLinkAbout1985, 03-18 Permit App: 00004522 Plumbing Fixturesw
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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. - -nting of a permit does not presume to give authority to
violate or cancel the provisions of an othe state of I I - ws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
APPLICATION
DATE
Project # �5�.z.
Owner's Name Last First MI
/ A`-1 2-5l.- 65 _
Project Address (Street Name & Number)
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State 9Q , .
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Subdivision/Plat Name
Assessors Parcel#Lot
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Block
Plat #
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Address
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City I
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State
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Zip
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Phone
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Business Phone
Contractor
Address
City
I State
Zip
Phone
Contact
License #
Business Phone
Describe Work
Bar Sink(s):
Drinking Fountain(s):
Floor Drain (s):
Washing Machine(s):
Doh Wshr(s): 1
Garb Disp(s):
Kit Sink(s):
Lndry Tray(s): • f
Sew Eject(s):
Urinal(s):
WtrCloset (s): 2
Lav(s):
Shower(s):
Tub(s): '
Bidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer Y N Septic/HealthNo.:
Electric Water Heater(s):
Drains -Roof:
REPAIR OR ALTERATION: Drainage, Vent, Water Piping/Treatment: Y N
Lawn Sprinkler System(s), including backflow device on any one meter:
Vacuum breakers or backflow devices in excess of line 16: 1-5:
(00 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. - -nting of a permit does not presume to give authority to
violate or cancel the provisions of an othe state of I I - ws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
APPLICATION
DATE