1986, 05-06 Permit App: 00010837 Plumbing Fixtures i
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
iProiect#
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Owner's Name Last First MI
Project Address(S reet Name&Number) l
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70 1' (Jis7^0-
City , State / ) Subdivision/Plat Name
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Assess>f rs Parcel# Lot Block Plat#
Applicant ---
,o Address sr
W,G GC3n/Z � 1 1HM!^i�� /v �c>S28 r
City State/, ' Zip Phone
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Business Phone
Contractor /0/V" ?N d Iti1 Address /v S 2 0 lj ST-
Two Ce0A t s
City State Zip Phone
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Contact / License# Business Phone
Ce ontoe G6o.f • c)c� *. 1,4`ZD2 2z 2 -� ,� p
77
Describe Work n - (`�it �
/ (, 0r•0d'e1 " A ,O10/AJ) /3DID I7/.")
Bar Sink(s): Drinking Fountain(s): Floor Drain(s): Washing Machine(s): /
Dsh Wshr(s): Garb Disp(s): Kit Sink(s): Lndry Tray(s): ! Sew Eject(s):
Urinal(s): Wtr Closet(s): Lav(s): Shower(s): / Tub(s): Bidet(s):
N Other: Type;
W
CC
0
XWaste/Grease Interceptor(s):
LL
LL Sewer Y N Septic/Health No.:
O
CC
W
m Electric Water Heater(s): Drains-Roof:
2
0
Z 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: (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.
SIGNATURE OF _ APPLICATION
OWNER OR AGENT .—+4 L/� °�`�J DATE