1985, 04-22 Permit App: 00005075 Plumbing Fixtures 1'
;, PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name , (Last) (First) (M) Department Use Only
... Q /��YY4;LilIt r..."11/ Project No.
2 Project Address(Not Mailing Address) Space Zip
t. 19}7 AA 6p rar u. r---'
3 City/Community State Subdivision/Plat Name
4 Assessor Parcel No.
( g,i�(01 1 Lot Block
5, lir
16tor Firm Name Street Address
17 ZipCity State Phone
eta v 6cok��, a. ( ) 6'3s'-ooeb6
18 Contact Person reNo. Phone if different than above
628 M/1;F7 P- /62,57-
8
Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work: New , ; Addition/Alteration El El; Replace/Repair Total Number
of Fixtures: /A
10 Applicant Name Street Address
11 Zip City State Phone
( )
* - *
9 Bar Sink(s): Drinking Fountain(s): Floor Drain(s): Washing Machine(s): /
10 Dsh Wshr(s): /
Garb Disp(s): Kit Sink(s): /
Lndry Tray(s): / Sew Eject(s):
11 Urinal(s): WtrCloset(s) Lav(s): Shower(s): / Tub(s):
/
Bidet(s):
co Other: Type;
W
CC
0
X12 Waste/Grease Interceptor(s):
U.
LL
O 13 Sewer Y N Septic/Health No.:
C
W
03 14 Electric Water Heater(s): ` Drains-Roof:
2
D
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 any other state of local laws regulating construction or the performance of
construction.
I
SIGNATURE OF iff APPLICATION .--
OWNER OR AGENT .�;!�.,i _ DATE 07,' S`.S