1985, 08-08 Permit App: 00006849 Plumbing Fixtures 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
t'L/O(0'4(�... ( 5--(• ` Project No.
2 Project Address(Not Mailing Address) Space Zip
ry (t( 1 ' cC.t," I‘e� C1".
3 City/Community l State Subdivision/Plat Name
4 Assessor Parcel No. Lot Block
16 Contractor Firm Name Street Address a X
IAl�t'e r(mow b ,Ay /E�) pc) 3
17 Zip I City State Phone
7?O,2S-o pP3 1 NE's► 41 I%(c c.tioA. (el*) DRS-
18 Contact PersonLicense No. Phone if different than above
IA., �� tui...v I A(vos,A,p /Fe;2)4
8 Owner/Agent(If different than#1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work: New k; Addition/Alteration 0 ; Replace/Repair ElTotal Number /6
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): ` Lndry Tray(s): Sew Eject(s):
11 Urinal(s): Wtr Closet(s): Z Lav(s): a— Shower(s): / I Tub(s): / Bidet(s):
N Other: Type;
W
CC
D
X12 Waste/Grease Interceptor(s):
LL
L.L. 13 Sewer Y (D1 Septic/Health No.:
o
cr
W
03 14 Electric Water Heater(s):/ Drains-Roof:
n
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+:
/6x f fa -7`/U 5-e °�
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 APPLICATIO�`�j
OWNER OR AGENT
DATE �i n� p�