1985, 08-21 Permit App: 00007076 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
r t Project No.
2 Project Address(Not Mailing Address) Space Zip
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3 City/Community 7 State ,) Subdivision/Plat Name
4 Assessor Parcel NoLot Block
.icy •
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16 Contractor Firm Name Set Addre
17 Zip City State Phone
18 Contact Person V License No. _Phone if different than above
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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
( )
* *
9 Bar Sink(s): Drinking Fountain(s): Floor Drain(s): Washing Machine(s): I
10 Dsh Wshr(s): Garb Disp(s): Kit Sink(s): /
Lndry Tray(s): Sew Eject(s):
11 Urinal(s): Wtr Closet(s): 1 Lav(s): .2/ Shower(s): Tub(s): / Bidet(s):
IL
Other: Type;
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X12 Waste/Grease Interceptor(s):
U-
0
O 13 Sewer Y N Septic/Health No.:
CC
W
1 14 Electric Water Heater(s): / Drains-Roof:
D
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 • a rother state of local laws regulating construction or the performance of
construction.
SIGNATURE OF APPLICATION ,-';:7(
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OWNER OR AGENT = p
' ' - DATE �`, ,Y/ i