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1984, 10-16 Permit App: 00002842 Plumbing Fixtures , , PLUMBING PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND 1 Owner's Name (Last) 7 i first) (M) Department Use Only l///O_J•i Project No. 2 Project Address(Not Mailing Address) Space Zip /02c ? f) 7/0(ad 3 City/Community State Subdivision/Plat Name 4 Assessor Parcel No. I Lot Block iziR4/2- 2_to o 167actor Fir ame Street Address iziodz4 17 ZipState ���7& I City,oma Phone - (- ) cia5-sL7 18 Contact Person License No. Phone if different than above k. I (9j0 5-'e o)f0 d`( 8 Owner/Agent(if different than 1 above) Business Address 9 Zip City State Phone ( ) 15 Describe Work: New ❑ ; Addition/Alteration ❑ ; Replace/Repair LI Total Number CP-T__. of Fixtures: 10 Applicant Name Street Address 11 Zip City State Phone ( ) * i * 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): 43, Lav(s): / Shower(s): Tub(s): I Bidet(s): 26 u) Other: Type; W cc n X12 Waste/Grease Interceptor(s): E.- U.W O 13 Sewer Y N Septic/Health No.: CC W m 14 Electric Water Heater(s): Drains-Roof: 2 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+: 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 . - tate of local laws regulating construction or the performance of construction. SIGNATURE OF APPLICATION/0 W OWNER OR AGENT DATE 1P ��dd