1985, 04-29 Permit App: 00005210 Plumbing Fixtures PLUMBING PERMIT APPLICATION WORKSHEET
A PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Names. (Last) -_ (First) (M) Department Use Only
t' __I--Vi% Project No.
2 Project Address(No Mailing Address) Space Zip
/5- c_51244.4,te.A-- grJec_ 0,4 .
3 City/Community I State Subdivision/Plat Name
4 Assessor Parcel No. I Lot Block
16 for Firm me Str t Addre
17 Zip9P 4,2D (City � State Phone
18 Contact Person F.
License No. Phone if different than above
Ij h4' p hi /‘.2 -L----
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
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): WtrCloset(s): Lav(s): Z Shower(s): / Tub(s): / Bidet(s):
cn Other: Type;
W
CC
D
X12 Waste/Grease Interceptor(s):
LI
b. 13 Sewer Y N Septic/Health No.:
O
CC
W
CO 14 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 - sy other state of local laws regulating construction or the performance of
construction. A./
SIGNATURE OF APPLICATION
OWNER OR AGENT Y.0- _... 111 '.! ; DATE