1985, 07-01 Permit App: 00006358 Plumbing Fixtures PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Names_- (Last) (First) (M) Department Use Only
jProject No.
2 Project Address(Not I aili g Address) y�' Space Zip
3 City/Community State Subdivision/Plat Name
4 Assessor Parcel No. I Lot Block
16 Contr c. tor Firm Nang Street ddd}ress
L
,t 1
• 17 Zip City State Phone
Col 9' C.; � > .c
18 Contact Person License No. Phone if different than above
11i M/Fi/' /1
8 Owner/Agent(if different than#1 above) Business Address
▪ 9 Zip City State Phone
15 Describe Work: New Q'; Addition/Alteration ❑ ; Replace/Repair ❑ Total Number /
of Fixtures: /
10 Applicant Name Street Address
11 Zip City State Phone
,r *
9 BarSink(s): Drinking Fountain(s): Floor Drain(s): f 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): Lav(s): Shower(s): Tub(s): Bidet(s):
m Other: Type;
CC
I- 12 Waste/Grease Interceptor(s):
LL
LL 13 Sewer Y N Septic/Health No.:
O
CC
CO 14 Electric Water Heater(s): / Drains-Roof:
2
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 . ' of er state of local laws regulating construction or the performance of
construction.
SIGNATURE OF APPLICATION 7 (7
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OWNER OR AGENT . % DATE >
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ADDRESS S. 3809 Skipworth Court STYLE 1002f
. LEGAL DESCRIPTION Lot 4 Block 1 Chester Heights Addition
APPLICANT Tupper Inc. POWER Inland Power & Light
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JOB # 803 WATER Model Irrig.
SCALE 1" = 20' approx.
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