1984, 08-21 Permit App: 00001909 Plumbing Fixtures•
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name /i'(First) (M)
r QProject
Department Use Only
No.
2 Project Address (pot Mailin Addr ) Space Zip
3 City/ itO
le%X(P
state462,
rf
Subdivision /Plat Name
4 Assessor P I No.
Lot
I
Block
16 Contractor r..Ncarier
cS r u LA1,Oi iti .
Street Address
17 Zip
City i
State
Phone
( )
18 Contact r4,)Licensip
No.
Phone if different than above
8 Owner/ gent (if different than #1 above)
'
' Business Address
9 Zip
City
State
Phone
( )
15 Describe Work: New X ; Addition/Alteration ❑ ; Replace/Repair ❑ 7 Total Number
of Fixtures: / /
10 Applicant Name
Street Address
11 Zip
City
State
Phone "0 775-7,
9 Bar Sink(s):
Drinking Fountain(s):
Floor Drain(s): /
Washing Machine(s): /'
10 Dsh Wahr(s): /
Garb Disp(s):
Kit SInk(s):
Lndry Tray(s):
sew Eject(s):
11 Urinal(s):
WtrCloset (ay
Lav(s):
Shower(s): / I
Tub(s): J /
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:
(005+ :
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 •f a permit does not presume to give authority to
violate or cancel the provisions of aj y other ate of Ioca�rws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
APPLICATION
DATE
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