1985, 10-31 Permit App: 00008504 Plumbing Fixtures 4 V
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- PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
IProject# s .e,)
Owner's Nam Last First MI �V
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ProjectAddress(Strut Name&Number) q/1 1 7 p(
City l State Subdivision/Plat Name
Assessors Parcel# (" [s'o f;� Lot Block Plat#
Applicant (® Y Address
City I State Zip Phone
Business Phone
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City,. State Zip Phone
Cont t Licena Business Phone
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Describe Work 9 `,
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BarSink(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): Wtr Closet(s): 1 Lav(s): s. 1 Shower(s): Tub(s): ---1 Bidet(s):
W
Other: Type;
CC
D
X Waste/Grease Interceptor(s):
L
U- Sewer Y N Septic/Health No.:
O
CC
W
COElectric Water Heater(s): i 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: (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 o ny o er state of local laws regulating construction or the performance of
construction.
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SIGNATURE OF APPLICATION / -----
OWNER
OWNER ORAGENT - ' 1 DATE 4:y:1/...„7