1986, 01-24 Permit App: 00009555 Plumbing Fixtures PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
IProject#
Owner's Name Last �r' First MI
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Project Address jStreet Name&Number)
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City State / L..1 Subdivision/Plat Name
Assessors Parcel# Lot Block Plat#
Applicant Address
City I State Zip Phone
Business Phone
Contcaetor'f � j�� ' r Adc�a� � ,
City„ 444 State Zip Phone
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Contact License Business Phone
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Describe Work
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Bar SInk(s):
-7-BarSink(s): Drinking Fountain(s): Floor Drain(s): Washing Machine(s):
Dsh Wshr(s): ) Garb Disp(s): Kit Sink(s): / Lndry Tray(s): Sew Eject(s):
Urinal(s): WtrCloset(Os Lav(s): // Shower(s): Tub(s): Bidet(s):
N Other: Type;CC
X Waste/Grease Interceptor(s):
U-
O
Sewer Y N Septic/Health No.:
OC
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: (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 of .ny other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF APPLICATION
OWNER OR AGENT l- DATE - �