1985, 06-10 Permit App: 00005921 Plumbing Fixtures PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's me (Last) (First) (M) Department Use Only
Project No.
2 Project Add (Not Mailing Address) Space Zip
/ g'42 5t.o.-141 And iS 112/ •
3 City/Community State Subdivision/Plat Name
4 Assessor Parcel No. I Lot Block
16 for Firm St A dyes
-,J N. r I _ �, o k 407.4 5/
17 Zip/'� Cit State Phone t)'kat() Z°f)
Se
18 Cofitact Person L�i acedia. �Bhone 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 ❑ Total Number 7"--"
of Fixtures:
10 Applicant Name Street Address
11 Zip City State Phone
( )
r
9 BarSink(s): Drinking Fountain(s): Floor Drain(s): Washing Machine(s):�
10 Dsh Wshr(s): Garb Disp(s): Kit Sink(s): / Lndry Tray(s): I Sew Eject(s):
11 Urinal(s): WtrCloset(s3 Lav(s): Shower(s)' Tub(s): Bidet(s):
Other: Type;
CC
X12 Waste/Grease Interceptor(s):
LL
LL 13 Sewer Y N Septic/Health No.:
O
CC
C1:1 14 Electric Water Heater(s): / Drains-Roof:
Z 15 REPAIR OR ALTERATION: Drainage,Vent,Water Piping/Treatment: Y N
16 Lawn Sprinkler System(s),including backf low 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 .t r-r state of local laws regulating construction or the performance of
construction.
SIGNATURE OF APPLICATION ••••- 1c) ----
OWNER OR AGENT /Kind tip DATE /� �