1985, 09-17 Permit App: 00007640 Plumbing Fixtures • ,PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Nam /0
e__ (Last) (First) (M)
�, Department •
Use Only '
/f f) fj F t Project No.
�
2 Project Address(Not�fvla�ing Address) Space
Zip
i=. R/4-7,2 1 ,_5'sa- tit W1rY iL` IX, %"f-
3 City/Community State Subdivision/Plat Name
4 Assessor Parcel No. Lot Block
Filick3)
16 Co for Firm Ns3�ne 1 Stree ddress
4Mit,Lc L' ,i-ke` 1114 II r f'A ? l /
17 Zip /, j City �j / State /�y 7 Phone( ),_c---,-74_;-- ���
vef2
18 Contact Person License No. Phone if different than above
NA/ g 04 /16;2,113-
8 Owner/Agent(if different than#1 above) ' Business Address
9 Zip City State Phone
( )
15 Describe Work: New Addition/Alteration ❑ ; Replace/Repair E Total Number ,-.
‘' of Fixtures: //(,)
10 Applicant Name Street Address
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): /9 Lndry Tray(s): I Sew Eject(s):
56
11 Urinal(s): Wtr Closet(s): ..-,"4 Lav(s): Shower(s): L/' Tub(s): Bidet(s):
m Other: Type;
W
CCD
X 12 Waste/Grease Interceptor(s):
U-
0
O 13 Sewer Y N Septic/Health No.:
CC
W
m 14 Electric Water Heater(s): t 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 provision f any other state of local laws regulating construction or the performance of
construction.
{-Ls)
SIGNATURE OFd � PPLICATION (/ / 7 , � `--
_44 OWNER OR AGENT 21,C. f a1CP .2.
I