1986, 08-07 Permit App: 00012582 Plumbing Fixtures AN
`"' PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
I Project# ,2582-
Owner's Name /� Last �. First MI
Project Address(S�reet mf1,4umber) ,�wt t r e t e (1_4 A
City State Subdivision/Plat Name
Assessors Parcel# Lot Block Plat#
Applicant Address
City 1 State Zip Phone
Business Phone
Contractor / I 1 Address G
I i�'Vv LTJ `5 t k_3 L- P.-. I-G . . r�, , f�X 4 //
City, , State 11 Zip Phone ,
, /'i? +SC-4,t`/ % L%, /�', /' _3 6 - Com' a
Contact License# Business Phone
t1A1 P rd //,)2,1-1-
Describe Work ._.,
/0 I— IY+ierr_r c-,
BarSink(s): Drinking Fountain(s): Floor Drain(s): I Washing Machine(s): /
Dsh Wshr(s): Garb Disp(s): Kit Sink(s): / Lndry Tray(s): Sew Eject(s):
Urinal(s): Wtr Closet(s): 7Lav(s): 7 Shower(s): / Tub(s): / Bidet(s):
W
Other: Type;
CC
D
I- Waste/Grease Interceptor(s):
LI
tL Sewer Y N Septic/Health No.:
O
CC
W `
COI Water Heater(s): / I Draino-Roof:
0
Z REPAIR OR ALTERATION: Drainage,Vent,Water Piping/Treatment: Y N
Lawn Sprinkler System(s),including backflow device on any one meter:
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 if any other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF / APPLICATION
OWNER OR AGENT �� /� DATE :�