1984, 07-30 Permit App: 00001509 Plumbing Fixtures PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name ) (First) (M) Department Use Only
Project0 ir ... ather/1
No. 1� �
2 Project Addr (Not Mailing(te:i.7f.ast
r Space
Zip
es-ly-,
3 City/Co Wily / State Subdivision/Plat Name
,VL' A19)-e .
4 AssessoirPfircel No. I Lot Block
16 Contractor Fir Name// /7 (LC'.
Stree dress
/tit Wi&dit' I d`'/44;eP
17 Zip Cit ( ate i Phone
r /1 1,1/A ( ' 7...C'
18 Contact Persy^ LicenN No. Phone if different than above
/(-4(A..- - Le cjC S/it /6-_-317/
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City I State Phone
( )
15 Describe Work: Newt; Addition/Alteration 0 ; Replace/Repair ❑ Total Number
// of Fixtures: "54`7 456-76 tic,
10 Applicant Name Street Address
11 Zip City State Phone
( )
* *
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): Wtr Closet(s): 3 Lav(s): 4/ Shower(s): I Tub(s): Bidet(s):
y Other: Type; 7
W
CCD
I- 12 Waste/Grease Interceptor(s):
LL
LL 13 Sewer Y N Septic/Health No.:
O
cc
W
m 14 Electric Water Heater(s): / Drains-Roof:
2
m
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 o y other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF H APPLICATION ��
OWNER OR AGENT G t DATE 7�'t�J