1986, 07-29 Permit App: 00012399 Plumbing Fixtures PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
IProject#
Owner's Name
1/22%VA /z7,4. Firs MI
Project Address(Street Name&Number)
o� 41 /
Gy .5h R lr t, (7_Ec.A-
City State Subdivision/Plat Name
(-U Pt-
Assessors Parcel# Lot Block Plat#
Applicant Address
City I State Zip Phone
Business Phone
Contractor 1
Addr �� / „0-4v5 74.i/49 L�
City ��State v.-JD//� Zip Phone
Contact License# Business Phone
t�-� rN r� P *I s 1-'!<r4 s ��-
Describe Work ��
/ /C Gc-) dYJPG ytsz?
Bar Sink(s): Drinking Fountain(s): Floor Drain(s): / Washing Machine(s):
Dsh Wshr(s): Garb Disp(s): Kit Sink(s): / Lndry Tray(s): Sew Eject(s):
Urinal(s): WtrCloset(s): / Lav(s): Shower(s): Tub(s): / Bidet(s):
y Other: Type;
W
CC
X
Int7- r--4-1.-"-e
I— Waste/Grease
Interceptor
LL
LL Sewer Y N Septic/Health No.:
O
CC
W
m Electric Water Heater(s): Drains-Roof:
2
Z REPAIR OR ALTERATION: Drainage,Vent,Water Piping/Treatment: Y N
43
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 of any other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF / 0,1 ,"Z.--APPLICATION
OWNER OR AGENT _ �� �'" - DATE