1985, 05-03 Permit App: 00005335 Plumbing Fixtures • PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Nam38 (Last)._____..-- (First) (M) I Department Use Only
�� i Project No.
2 Project Address plotIMailing Address) l" ,� jj Space Zip
—C. `i Ul ``16.p ur)p "'`7ii (�' L
3 City/Community State Subdivision/Plat Name
4 Assessor Parcel No. I Lot Block
(I/e4 2 ) . )- s
16_920.triSr Firm darn ['� Street Address �'
—1-1- . &, gi9-7,.,,--Z--z6/
17 OZip^ City` t State/ 1 Phone �2,,
18 Contact Person L�i`cer�se No. Phone if different than above
�j 5 H,yg ) /(10, ---)'--)3
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work: New X; Addition/Alteration ❑ ; Replace/Repair E Total Number
of Fixtures: /7
10 Applicant Name Street Address
11 Zip City State Phone
( )
9 Bar Sink(s): Drinking Fountain(s): Floor Drain(s): i Washing Machine(s):l
10 Dsh Wshr(s): Garb Disp(s): Kit Sink(s): f Lndry Tray(s): Sew Eject(s):
11 Urinal(s): Wtr Closet(s): 2 Lav(s):� Shower(s): Tub(s): Bidet(s):
•,._)
co Other: Type;
W
CC
0
X12 Waste/Grease Interceptor(s):
LL
ll
O 13 Sewer Y N Septic/Health No.:
cc
W
03 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 of any other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF � APPLICATION , -tet, �. -----
OWNER OR AGENT / )'.7(4..Z2.,
� ) _....2 ___--- DATE � )