1984, 08-24 Permit App: 00001925 Plumbing Fixtures 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
LA P UA-- Project No.
2 Project Address(Not Mailing Address) Space Zip
/+Ufa LOf )
3 City/Community State Subdivision/Plat Name
PO 4 Z`)/'
4 Assessor Parcel No. Lot Block
16 Contractor Firm Name Street Address
17 Zip City State Phone
18 Contact Person License No. Phone if different than above
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
15 Describe Work: New ❑ ; Addition/Alteration ❑ ; Replace/Repair ❑ Total Number
of Fixtures:
10 Applicant Name Street Address
11 Zip City State Phone
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9 BarSink(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): Shower(s): I Tub(s): Bidet(s):
LO Other: Type;
W
CC
D
X12 Waste/Grease Interceptor(s):
lL
O 13 Sewer Y N Septic/Health No.:
CC
W
CO 14 Electric Water Heater(s): Drains-Roof:
2
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
OWNER OR AGENT DATE