1985, 09-17 Permit App: 00007638 Plumbing Fixtures ' 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
1 �;y c-- I_ i ? Project No. -74e
-�L � i
2 Project Addressp (Not ailing Address) f Space Zip
C' 4 /4? -ii 5l_-vtrt,tills: r rr 4L e'--
3 City/Community State Subdivision/Plat Name
4 Assessor Parcel No. I Lot Block
(73 3)
16 Contractor Firm Nameam1 Street Address ,�
"`� r_ v._ GDf, rke Pit's"! ie-1, 13e) X .26;7
1,•-•,
Zip City State Phone
—eli 6
18 Contact Person License No. Phone if different than above
JHN141)11 /62
8 Owner/Agent(if different than#1 above) ' Business Address
9 Zip City State Phone
( )
15 Describe Work: New X(_; Addition/Alteration El ; Replace/Repair ❑ Total Number 1
of Fixtures:
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): I Sew Eject(s):
11 Urinal(s): Wtr Closet(s): —1 --Lay(s): i Shower(s): (
Tub(s): / Bidet(s): 66
y� , ---
N Other: Type;
W
CC
D
X12 Waste/Grease Interceptor(s):
LL
LL
O 13 Sewer Y N Septic/Health No.:
CC
W
CO14 Electric Water Heater(s): / Drains-Roof:
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. ^,
SIGNATURE OF APPLICATION
OWNER OR AGENT r-- �.t!1i) _ DATE / / ' ,Y-�
l