1985, 10-29 Permit App: 00008492 Plumbing Fixtures PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
`Protect#
Owner's Name� Last First MI
S 4'
•
Project Address(Street Name��� ^t
? 7
City State Subdivision/Plat Name
Assessors Parcel# Lot Block Plat#
(-&Q ,12.)
Applicant Address
City State Zip Phone
Business Phone
Con C' r 1.!✓ ui (�/ P7 A D, iCJ , Z51/
//
Ci State Zip Phone r
Cdntact License# Business Phone
�µ SP, / /‘.07J-J--
Describe Work 1 ,
/ J x7l.L�� s
Bar Sink(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(s): 3 Lav(s): Shower(s): / Tub(s): Bidet(s):
Other: Type;
CC
XWaste/Grease Interceptor(s):
I
W Sewer Y N Septic/Health No.:
O
CC
W
COElectric Water Heater(s): / Drains-Roof:
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: (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 oth- state of local laws regulating construction or the performance of
construction.
SIGNATURE OF APPLICATION / 40,22,"
OWNER OR AGENT DATE ��