1986, 07-29 Permit App: 00012395 Plumbing Fixtures • G{-1 4 2'-')
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
I Project# f 23 9 g
Owner's Name Last st MI /
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Project Address(Street Name&Number) 41/2/ x C
City State Subdivision/Plat Name
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Assessors Parcel# Lot Block Plat#
Applicant Address
City I State Zip Phone
Business Phone
Contractor ^. ?/L Address
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City 1 State Zip Phone
o 1< -t— Wz. 15,72 o `7 ,-/e 5 - 34/?/
Contact License# Business Phone
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DescribeWork
A/CC (74,--/ L P/C-e._" /eV-(7
Bar Sink(s): Drinking Fountain(s): Floor Drain(s): C..s Washing Machine(s): d-`"
Dsh Wshr(s): Garb Disp(s): Kit Sink(s): _- Lndry Tray(s): Sew Eject(s):
Urinal(s): Wtr Closet(s): '2., Lav(s): Z.,. Shower(s): 7 Tub(s): , / Bidet(s):
07 Other: Type;
W
CC
0
X Waste/Grease Interceptor(s): f /�7 f,,, S
LI' Sewer Y N Septic/Health No.:
O
CC
W
CO Electric Water Heater(s): / Drains-Roof:
2
Z REPAIR OR ALTERATION: Drainage,Vent,Water Piping/Treatment: Y N
Lawn Sprinkler System(s),including backflow device on any one meter:
Vacuum breakers or backflow devices In excess of line 16:1-5: (Or)5+:
4 -_-; 40 -i-- (1- = 3 r
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 � PLICATION
OWNER OR AGENT ‹..._...---____--___ ,,c:
-- �` �' DATE _2