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1986, 06-05 Permit App: 00011490 Plumbing Fixtures PLUMBING PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND A 1 Owner's Name (Last) /!/ (First) (M) Department Use Only NI y l i tt�C9 11,a It k Project No. /iOo 2 Project Address(Not Mailing Address) Space Zip . Ca ,2.7 S ' .5'ai e.,/1a hl d 3 City/Commu ty State. Subdivision/Plat Name �i cile-'_ i�' ("C&S 4 Assessor Parc No. I Lot Block 16 Contractor Firm Name Street Address -7----- --.6'- f-w f vv i eS .r-A(C_ #6 ©7 C - >-J�ett 1 17 ZipI City State Phone `�`7s Oo 5,, Z'-a-. 'e i, s4 ( ) 18 Contact Person • License o. Phone if different than above / r'c� tiL' '1�' IBE-N---27BL 8 Owner/Agent(if different than#1 above) Business Address 9 Zip City State Phone ( ) 15 Describe Work: New Addition/Alteration 0 ; Replace/Repair ❑ Total Number P� of Fixtures: ::— a 10 Applicant Name Street Address / S 11 Zip City State Phone 6-3 z'y ( ) 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): Shower(s): / ! Tub(s): / Bidet(s): co Other: Type; W CC D X12 Waste/Grease Interceptor(s): W 13 Sewer Y N Septic/Health No.: L.," O CC W m 14 Electric Water Heater(s): Drains-Roof: 0 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 •• . T-11 ranting of a permit does not presume to give authority to violate or cancel the provisions o . y other state f local la lating construction or the performance of construction. SIGNATURE OF APPLICATION OWNER OR AGENT L DATE ',/,...5./r4, OWNER