1984, 12-28 Permit App: 00003827 Plumbing Fixtures J
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name , (Last) (First) (M) Department Use Only ----)
uJ L=- 1 L/l/: , Project No. 2 G
2 Project Address lot Mailing Address) ,� Space Zip
r yq/y L-.Je`,.A14-6/L— -I I.
3 City/Community State Subdivision/Plat Name
4 Assessor Parcel No. I Lot Block
16 Contr., • Firm Name // Strr tt Address
. J 0 v «, I' cc.r�4 E- el...// . i( 23,- it t'' i --/
17 Zip City State Phone i
i:
18 Cintaci Person VLicense No. Phone if different than above
`H/1/ ,(7PA/ //2-.11
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work: New D ; Addition/Alteration ❑ ; Replace/Repair ❑ Total Number
of Fixtures: /2"}
10 Applicant Name Street Address
11 Zip City State Phone
( )
* *
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): Lay(s): I Shower(s): Tub(s): / Bidet(s):
rn Other: Type;
W
CC
D
X12 Waste/Grease Interceptor(s):
LL
LL'
O 13 Sewer Y N Septic/Health No.:
CC
W
CO 14 Electric Water Heater(s): j' Drains-Roof:
D
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 other state of local laws regulating construction or the performance of
construction. ---
SIGNATURE OF APPLICATION /_� � ` �
OWNER OR AGENT - " 1 k: DATE ./:1,3 „/:
j� /