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1986, 04-22 Permit App: 00010639 Plumbing Fixtures ,ivG PERMIT APPLICATION WORKSHEET PI,ZASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND 1Pr0iectM /14,33 Owner's Name Last /7477141=, First MI l I�ii C (c / Project Address(Street Name Number) /l ./,boy S POP City State Subdivision/Plat Name Assessors Parcel# Lot Block Plat# Applicant Address City I State Zip Phone Business Phone Contract( / ! //, jI Igni /��I��%es. Addres gyCity �[ /ta{e 7/y Zip Phone S Contact- Licen k Business Phone K' 5A/ 1 iT Describe Work A /V tg1 .5 ��— Y©7/3— ntj 1y ,Lf 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): Lav(s): Shower(s): / Tub(s): / Bidet(s): W Other: Type; CC I- Waste/Grease Interceptor(s): U- W Sewer Y N Septic/Health No.: O CC m Electric Water Heater(s): / Drains-Roof: 2 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 -p: of work, including inspection requirements, will be com- plied with whether specified her-in or not. T e s rantingof a permit does not presume to give authority to violate or cancel the provisions any other ..ta of local laws regulating construction or the performance of construction. SIGNATURE OF / OrP APPLICATION OWNER OR AGENT `� A 'j- DATE V