1985, 05-21 Permit App: 00005514 Plumbing Fixtures s
-. 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
47g 5-kL%iti 6 �pr j -7— Project No.
2 Project Address(Not ailing Address) /"` Space Zip
a ---) / __) 167/ r) q�2 :'
3 City/Commu ity / State Subdivision/Plat Name
71/LI
4essor Parcel No. Lot Block yL.
16 Contractor Firm Name Street Address
Ci D-f C c-- ,. ,,L2 S / A-". 6-3.C'7 (3 Gil/mk. 1-__.
17Zip City State Phone
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18 Contact Person 4/ License No. Phone if different than above
OD f/C..-( / B/2
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work: New Ar; Addition/Alteration D ; Replace/Repair ❑ 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):
10 Dsh Wshr(s): Garb Disp(s): Kit Sink(s): Lndry Tray(s): Sew Eject(s):i
11 Urinal(s): Wtr Closet(s): 1 Lav(s): f Shower(s): Tub(s): Bidet(s):
rn Other: Type;
W
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0
X12 Waste/Grease Interceptor(s):
it
tL
O 13 Sewer Y N Septic/Health No.:
CC
W
CO 14 Electric Water Heater(s): Drains-Roof:
2
0
Z 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 .\ APPLICATION r---.:2 1 -��.
OWNER OR AGENT - ! - v , DATE f / L ,