1985, 10-14 Permit App: 00008113 Plumbing Fixtures 4 .
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
1Art,,,,,,,_1 -- LA " er_ , Project No. r�8.
2 Project Adress(Nog Address) Space Zip
A-1, /)11, /, r l7 (14--
3 City/Community State Subdivision/Plat Name
4 Assessor Parcel No. (lqlq)
I Lot Block
16 CoQtra,tof Firm Name.„,---/ Street Address
j ''
17 Zi A City State Phone
`/`7 7' ' i, ;/ (-1 e/ °7"�Cr /__ �
:/ 7 - , ( ),�iJ ( -! )f)c4 -:
18 Contac(((Person ./j Ljcense-No. Phone if different than above x-
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work: New Addition/Alteration El ; Replace/Repair ❑ Total Number
of Fixtures: //}
10 Applicant Name Street Address
11 Zip City State Phone
( )
* *
9 BarSink(s): Drinking Fountain(s): Floor Drain(s): ` /
Washing Machine(s): J
10 Dsh Wshr(s): Garb Disp(s): Kit Sink(s):/ Lndry(/Tray(s): Sew Eject(s):
l --7
11 Urinal(s): Wtr Closet(s): Lav(s): `.- Shower(s): / Tub(s): i Bidet(s):
W
Other: Type;
CC
D
X12 Waste/Grease Interceptor(s):
LI
LL'
O 13 Sewer Y N Septic/Health No.:
CC
W
03 14 Electric Water Heater(s): j 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 arty-pt r state of local laws regulating construction or the performance of
construction.
fes--, ;
SIGNATURE OF , APPLICATION ) 4:/' ----
OWNER OR AGENT A i )/ DATE -