1985, 05-03 Permit App: 00005337 Plumbing Fixtures•
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Narge (Last (First) (M)
G i'r t/' __"--41e/
( Department Use Only
Project No.
2 Project Addr ( t Mailing Address)Space Zip
.6. (-70i/ V '/ 4 . u_ r4 1 (, •
3 City/Community
I State
Subdivision/Plat Name
4 Assessor Parcel No.Lot
C5i13>1
Block
5337
16 rector Name{
---J6GLYLJ U ` ke.) Pt _
J , Street Addressy"C/
i Cry /
17 Zip%
City ////�++++���� �cc���� se,
State /Q� 1
Phone
18 Contact Person u J__Igeose No.
k44 -8P/ /'\-/_
Phone if different than above
8 Owner/Agent (If different than #1 above)
Business Address
9 Zip
City
State
Phone
( )
15 Describe Work: New ; Addition/Alteration ❑ ; Replace/Repair IDTotal
Number /
of Fixtures: 0
10 Applicant Name
Street Address
11 Zip
City
State •
Phone
( )
9 BarSlnk(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):
1 I Shower(s): t! `
f Tub(s): /
1 Bidet(s):
Other: Type;
12 Waste/Grease Interceptor(s):
13 Sewer Y N Septic/Health No.:
14 Electric Water Heater(s): /
L
Drains -Roof:
15 REPAIR OR ALTERATION: Drainage, Vent, Water Piping /Treatment: Y N
16 Lawn Sprinkler System(8), including backflow device on any one meter:
17 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 _/4;t
OWNER OR AGENT / , DATE L /
•