1984, 11-16 Permit App: 00003402 Plumbing Fixtures •
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PLUMBING PERMIT APPLICATION WORKSHEET ,
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) (M) Department Use Only .-,2 e(im 7/
�`%> C �0/[/S `CV, [Project No. 1+
2 Project Address(Not Mailing Address) Space
- / / / S `lt/' e.f,)
- "J -- r)Al Zip
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3 City/Community State Subdivision/Plat Name
4 Assessor Parcel No. Lot Block
2 54 03D q 3
16 Contractor Firm Name r Street Address _
17 Zip City t * State
990 PPhone
ek �v �4 ( ) 7 517 <,-6
18 Co erso Li ense No. Phone if different than above
' %, ! -c%9i.) ALA/V / /,j 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):/ 1 Lndry Tray(s): Sew Eject(s):
11 Urinal(s): Wtr Closet(s): 1 Lav(s): Shower(s): Tub(s): Bidet(s):
N Other: Type;
W
Cr
7
X12 Waste/Grease Interceptor(s):
LL
11 13 Sewer Y N Septic/Health No.:
O
C
W
m 14 Electric Water Heater(s): Drains-Roof:
2
7
Z 15 REPAIR OR ALTERATION: Drainage,Vent,Water Piping/Treatment: 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 , t / / ii APPLICATION r/
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OWNER OR AGENT � - 1 DATE ��