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1985, 07-26 Permit App: 00006590 Plumbing Fixtures 4 :34- "-- PLUMBING PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND IProject# C ' Owner's Name Last First MI -r- T V/' i2Ke A r 7'/zu If- ect Address(Street Name&Number) /, ProE. /0621 S,6ri q / /b' 4116. Ci ate Subdivision/Plat Name © K�. -yt E )/1/ -= ,�ofe -C-- Z1 10 KO Ass sors Parcel# Lot Block Plat# (•?5:'4- 2-t0c Applicant Address City I State Zip Phone Business Phone Contractor Address 5e e_ ROSS 171fc.- $ 1 'h 5'63 Yr + ort v= City 1 State Zip Phone 5:e0 A/CL--1,1 W /Y\ 2.12. .5-3 tic -3o 7/ Con License# Business Phone _ Nt= e 133< KP S'4-yh '- - Describe Work — w� 472-CIA, / 4 9 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): (j/- Urinal(s): WtrCloset(s): , / Lay(s): j,,,-. Shower(s): Tub(s): j/ Bidet(s): m Other: Type; i/ w CC D XWaste/Grease Interceptor(s): IT O Sewer V N Septic/Health No.: CC W m Electric Water Heater(s): Drains-Roof: 2 D Z REPAIR OR ALTERATION: Drainage,Vent,Water Piping/Treatment: Y N Lawn Sprinkler System(s),including backflow device on arty 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 / ,, APPLICATION G OWNER OR AGENT ,����'"`�' DATE 7 ` 2� '_` O