1984, 10-03 Permit App: 00002701 Plumbing Fixtures 1 •
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's . (Last) (First) (M) Department Use Only
.....----7
/ It0r � �tp di` Project No.
2 Project AddressOlot�ailing Address) Space Zip
t. 1lig Oo SMSA. e.r• -0le.0 C7)•
3 City/Community State Subdivision/Plat Name
4 Assessor Parcel No. I Lot Block
16 L -- --
Street Address
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17^'Zi 'City�� State Phone
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18 Co 'erson License No. Phone if different than above
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8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work: New El ; Addition/Alteration ❑ ; Replace/Repair ❑ Total Number /00
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): Sew Eject(s):
11 Urinal(s): Wtr Closet(s): 2, Lav(s): giii Shower(s): / Tub(s): / Bidet(s):
Other: Type;
W
CC
D
X12 Waste/Grease Interceptor(s):
L
OW 13 Sewer Y N Septic/Health No.:
CC
W
CO 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 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 /9� /3 ig
OWNER OR AGENT DATE [J/