1985, 04-23 Permit App: 00005108 Plumbing Fixtures . PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Nara. (Last) (First) (M) Department Use Only
Lt ,�49�r� Project No.
2 Project .12-_ .1
0 Mailing Address) ( ( Space Zip
7 i/ Q ze-�;AA AA�" 1-' 4-71'/ r-z - ;
3 City/Community State Subdivision/Plat Name
4 Assessor Parcel No. (�. 111`.'v � I Lot Block �fLi t.../
16 sa*dttor Firm N Str ,r Mdress
17� 4 i.� � .r--lie- Pc/-14, t:/), K,.),,�' :tel i/
Zi City State ,N, Phone
1 n^ � /
/7.? , /��V/ ketxe, 4 l_. ( ) .4„.:77 ---;-&e.,
G
18 Contact Person / License No. ,2bone if different than above
I1/8I'I/ /e,-,-',3-1-3
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
Total Number "''
15 Describe Work: New ,Ig.„; Addition/Alteration ❑ ; Replace/Repair ❑ ` f 1
of Fixtures: /
10 Applicant Name Street Address 1/ -
11 Zip City State Phone
( )
*
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): Sew Eject(s):
11 Urinal(s): Wtr Closet(s): `;,S Lav(s): ;`7 Shower(s): fi Tub(s): / Bidet(s):
Other: Type;
W
CC
D
X 12 Waste/Grease Interceptor(s):
U-
LL
O 13 Sewer Y N Septic/Health No.:
CC
W
CO 14 Electric Water Heater(s): / Drains-Root:
0
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. /
SIGNATURE OF �� APPLICATION -//
--,4-1l,--- - -
OWNER OR AGENT _0 . . �'. DATE �