1985, 06-17 Permit App: 00005994 Plumbing Fixtures ,..
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
•rn
1 Owner's Name// p,p(Last) t) (M) Department Use Only
`%e/► L S "I9e Y Project No.
2 Project Address(Not Mailing Address) "'` Space Zip
5 c//or1.,o Cs ' .0k . 79a 37
3 City/Community States Subdivision/Plat Name
JJd
•4 Assessor Parcel No. Lot Block l
255e —oil /0 i ,'�
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L
16 Contractor Firm Name Street Address
17 Zip City State Phone
18 Contact PerNon License No. Phone if different than above
k.Ari 0 Y 0/0E, we E - /76 4
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work: New IE ; Addition/Alteration ❑ ; 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): �/)�
AO
10 Dsh Wshr(s): Garb Disp(s): Kit Sink(s): Lndry Tray(s): Sew Eject(s): 3'
11 Urinal(s): Wtr Closet(s): / Lav(s): I Shower(s): / I Tub(s): Bidet(s):
G
CD Other: Type;
LU
CC
0
X12 Waste/Grease Interceptor(s):
LI
LL 13 Sewer 0 N Septic/Health No.:
O
CC
w
CCI 14 Electric Water Heater(s): Drains-Roof:
2
D
Z 15 REPAIR O ALTERATION: Drainage,Vent,Water Pi;)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 other state of local laws regulating construction or the performance of
construction. --7
edy, ,,,
SIGNATURE OF ' -46-4/ APPLICATION
OWNER OR AGENT
DATE /7