1986, 06-05 Permit App: 00011421 Plumbing FixturesPLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF•THE FORM YOU UNDERSTAND
31 00
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
OWNER OR AGENT
APPLICATION 6
DATE (�
Project # / / ti /
Owner's Name Last First MI
e N 1'%%/�5'7'1,"26gF'T
Project Address (Street Name & Number)
9410 7 E 5'i0 7/ -
City
State
Subdivision/Plat Name
Assessors Parcel #
Lot
Block
Plat #
Applicant
Address
City I
State
Zip
Phone
Business Phone
ntractgL
Address��
P Gti i m -s, [C
/61GO[H £L9#2
.01
City
State !
6(.209--
Zip
_9o2D QJ
Phone
32.,_:. s-6 00
Con IJ
(,
iC l- -- —•0 .L /51° -CT
LZhI/27--—•01.
Business Phone
Describe Work
BarSink(s):
Drinking Fountain(s):
Floor Drain (s):
Washing Machine(s):
Doh Wshr(s):
Garb Diep(s):
Kit Sink(s):
Lndry Tray (s):'
.
Sew Eject(s):
Urinal(s):
WtrCloset(a): % ,
C
Lav(s): /
Shower (s):
Tub(s): `/
Bidet (ay
rn
W
cc
Other: • Type;
D
1- X
Waste/Grease Interceptor(s):
1
O
C
Sewer Y N Septic/Health No.:
W
m
i
•
Electric Water Heater(s):
Drains -Roof:
D
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 any other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
APPLICATION 6
DATE (�