1986, 04-14 Permit App: 00010457 Plumbing Fixtures PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Project# /
Owner's Name Last First MI
Project Address(Street Name&Number)
5 a o-7 N . 14.Ec-Lere_
City State Subdivision/Plat Name
Assessors Parcel# Lot Block Plat#
Applicant Address
City I State Zip Phone
Business Phone
Contractor Address
City State Zip Phone
Contact- License# Business Phone
Describe Work
I l F krrue.c 5
Bar Sink(s): Drinking Fountain(s): Floor Drain(s): Washing Machine(s):
Deh Wshr(s): , Garb Disp(s): Kit Sink(s): 1 Lndry Tray(s): Sew Eject(s):
Urinal(s): WtrCloset(s): 3 Lav(s): Shower(s): Tub(s): 1 Bidet(a):
N Other: Type;
W
CC
XWaste/Grease Interceptor(s):
LL
Sewer Y ( N J Septic/Health No.:
OCC
\�
m 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: a (00 5+:
'tx f= (#/#15 sq.oa
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