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
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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