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1985, 10-25 Permit App: 00008340 Plumbing Fikxtures
r"/ PLUMBING PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND s. J Project p E3 , /e w Z er's Name Last First MI Project Address (Street Nwpik& Number) E. 183\\ ‘JF_12 LA1esJ1 City (0-V2EEOc CQ -rt, State t3 A Subdivision/Plat Name Aeeaeeors Parcel # Lot Block Plat ,1c 3c2& asa AAppfrapt \©. OX 2�4- City 6n12Frr3ACQ s I State �c, Zip 990/( Phone 22 -0444 Business Phone Co actorAddress City I State Zip Phone Contact License N Business Phone Describe Work p NE,,J rr-cS Bar Sink(s): Drinking Fountaln(s): Floor Drain (s): 2 Washing Machine(s): Dsh Wshr(s): 1 Garb Dlep(s): Kit Sink(s): ) Lndry Tray(s): I Sew Eject(s): Urinal(s): Wt Closet(s): A Lav(s): ./S A� Shower(s): �% L� Tub(s): 1 Bldet(a): Other Type; Waste/Grease interceptor(s): Sewer Y N Septic/Health No.: Electric Water Heater(s): Drains -Roof: REPAIR OR ALTERATION: Drainage, Vent, Water PIping/Treatment: Y N Lawn Sprinkler System(s), Including backflow device on any one meter: Vacuum breakers or backflow devices In excess of line 16:1-5: (005+ : W wQ LL D X LL O cc 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 OWNER OR AGENT APPLICATION DATE 10 —2S—CIS