1985, 10-14 Permit App: 00008115 Plumbing Fixtures•
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name A (Last) – (First) (M)
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/ () ^ Le Set _r
Department Use Only
Project No. g/ /s
2 Project Address o f a ing Address) Space Zip
rioo?L1//'IL ,c1`
8 City/Community
I State
ubdivision/Plat Name
4 Assessor Parcel No( I
)
Lot
Block
16 Cgptralor Firm N,a,j j
�C)L.IA /3f:L r14C� P P
Street Address ]
f�
Ri) r Y>e ,-f-4-7
17 Zip/ < -)City
—ire k��'2-/
>jr{(
State A_ - .
)
Phone( )y1-ee�
18 Contact//Person
Licen
,Ing -A/ g Phi /&
Phone if different than above
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
I State
Phone
( )
15 Describe Work: New ; Addition/Alteration 0 ; Replace/Repair 0
Total Number �1
of Fixtures: /e.)
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):
11 Urinal(s):
WtrCloset (s): _
Lav(s): �"�� '%
I Shower(s): /
1
Tub(s): /
Bidet(s):
Other: Type;
12 Waste/Grease Interceptor(s):
13 Sewer Y N Septic/Health No.:
14 Electric Water Heater(s): a
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 of a permit does not presume to give authority to
violate or cancel the provisions o - e her state of local laws regulating construction or the performance of
construction.
- r
SIGNATURE OF
OWNER OR AGENT
APPLICATION
DATE �1 �3 .5
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