1986, 07-28 Permit App: 00012344 Plumbing Fixtures PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
IProject#
Owner's Name Last First MI i
BO
Project Address(Street Name&Number)
• / 'r / cit 4 U FLc)
City State Subdivision/Plat Name
Assessors Parcel# Lot Block Plat#
Applicant Address
City I State Zip Phone
Business Phone
Contractor Address41-
n
anITIe-v �t,en .� >nren-( L,�c: Lam, /i /02_
City State Zip Phone
9 ,z_c)fi? i/6,, 7 —4'000
License# Business Phone
1I1T i I Uiv,T Ta P7- fs'�Cj C
Describe Work
I�ODrr,ortl •--742; r✓ .
Bar Sink(s): Drinking Fountain(s): Floor Drain(s): Washing Machine(s):
Dsh Wshr(s): / Garb Disp(s): Kit Sink(s): r Lndry Tray(s): Sew Eject(s):
Urinal(s): Wtr Closet(s): / Lav(s): Shower(s): Tub(s): / Bidet(s):
W Other: / 5,,,-L Type; acj...,,Q
CC
XWaste/Grease Interceptor(s):
U-
Il Sewer Y N Septic/Health No.:
O
CCW
CO Electric 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: (00 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 ��� 4/ APPLICATION
OWNER OR AGENT 4 DATEv2'O Ca Co