1985, 05-02 Permit App: 00005264 Plumbing Fixtures•
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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) (M)
C.
Department Use Only
Project No. 4:7 /_G. 7- f
2 Project Address (Not Mailing A dress) Space Zip
cgL) .- 7 .Q 37
3 City/Co munity j (`J
f/1/L .2 \
State /
(ir�/ L
Subdivision/Plat Name
4 Assessor Parcel No. ILot
Block
16 Contract r Firm Namg
Street Address ��j�
Zip
17 �� !' I
CityI. L Q GC.CE
1
Statee
Phone( ) ...`�- Lvc�C�
,Z
18 Contact Pe on
4.
License No. j� / j�
(/ ELL fi` i 16, s iC3
Phone if different than above
8 Owner/Agent (if different t an #1 above)
Business Address
9 Zip
City
State
Phone
( )
15 Describe Work: New ❑ ; Addition/Alteration Replace/Repair 0
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): f
10 Dsh Wshr(s):
Garb Disp(s):
Kit Sink(s):
Lndry Tray (s):
Sew Eject(s):
11 Urinal(s):
Wtr Closet (s):
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+:
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 �/�-J- APPLICATION
OWNER OR AGENT / t "/ DATE ���/�`}�