1985, 08-09 PErmit App: 00006795 Plumbing Fixtures•
co
W
2
t—
X
0
ccW
m
D
Z
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE -ONLY -THOSE PARTS OF THE FORM YOU UNDERSTAND
‘ 1 Owner's Name i^y/ Les Cols. (First) (M)
Department Use Only
Project No.
2 Project Address (Not Mailing Address)
`/1 a�(w��p^ o L
_ pace Zip
%//• cae.
3 City/Community
State
Name
4 Assessor Parcel N(277`
Lot
Block
f
L3(
16 Contractor ; N t S oil
�Y!/JVe
la '
Street Ad e.,,ss /
//Vflf/if�//C/ 9/
17 Zip
City
State
Phone( ) �) V" ' VO/
18 Contact Person
1
L7f--s,m'--4sPr se No.
Phone if different than above
8 Owner/Agent Of different than 41 above)
Business Address
. 9 Zip
City
1 State
Phone
( )
; Addition/Alteration 0 ; Replace/RepairTotal
15 Describe Work: New Ile; 0
Number
of Fixtures: gxyi k)5:1
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
9 Bar Sink(s):
Drinking Fountain(s):
Floor Drain (s): _
Z.-••
Washing Machine(s):
_•
10 Dsh Wshr(s):
Garb Disp(s):
Kit Sink(s): Z
LndryTray(s):
Sew Eject(s):
11 Urinal(s):
W 7
trCloset(s): /
Lav(s):
I Shower(s):
l
1 Tub(s): Z.....
Bidet (s):
Other: Type;
12 Waste/Grease Interceptor(s):
13 Sewer Y N Septic/Health No.:
14 Electric Water Heater(s): 4'f
(/`
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 local laws regulating construction or the performance of
construction.
SIGNATURE OF
APPLICATION
OWNER OR AGENT DATE