1984, 10-15 Permit App: 00002873 Plumbing FixturesN
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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)
Department Use Only
Project No.
2 Project Address (Not Mailing Address) Space Zip
L— // 7/ 4' 1.2 / lload
3 City/Community
State
Subdivision/Plat Name
4 Assessor Parcel No.
I Lot
Block
20/8
16 Contractor Firm Name
/7; c k izif /50Kiri
Street Address
y .77/0 /la�dc,! f .4
17 Zip
9aU 7
City
37"/-
State
ill'?"
Phone
( ) 5' i 7 G Y7r
18 Contact Person
License No.
Phone if different than above
8 Owner/Agent Of different than 91 above)
Business Address
9 Zip
City
State
Phone
( )
15 Describe Work: New CA--; Addition/Alteration ❑ ; Replace/Repair ElTotal
Number
of Fixtures:
10 Applicant NameStre
.4-7)7C l--50.1 Ph.,,,e4.
et Address
R'O , / .eze vie
11 Zip
P7107 &
City
�e.
tate
a3/7
Phone
( ) 2,'' cxe -s-
9
9 BarSink(s):
Drinking Fountaln(s):
Floor Drain(s): /
Washing Machine(s):
10 Doh Wshr(s): /
Garb Disp(s): j
Kit Sink(s): /
Lndry Tray (s): /
Sew Eject (s):
11 Urinal(s):
WtrCloset(s): a„.?
Lav(s):
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(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 18: 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. 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 4,1 / DATE /G -�— 'Y
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