1985, 03-18 Permit App: 00004582 Plumbing Fixtures PLUMBING PERMIT APPLICATION WORKSHEET
' PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's ie (Last) (First) (M) Department Use Only
/ L4.� p P?.s LQ1e, , Project No.
2 Project Address of ailing Address Space Zip
. t:1 1 q3 City/Community State Subdivision/Plat Name
35(o I/3 —flgrPf ge74 '`
4 Assessor Parcel No. I Lot Block 115F2- /�5
16 Con .r Firm Na Street Address
. rc rke, PW1 PO 'R.7 Xe /
17 Zi _ City State Phone
r2 C! C>f D ku-•v e---_ ZO,,/. t(_535_-z"(566
18 Cntact Person License No. Phone if different than above
8 Owner/Agent(If different than#1 above) Business Address
9 Zip City State Phone
,,// ( )
15 Describe Work: New y�; Addition/Alteration ❑ ; Replace/Repair ❑ Total Number ��"�,
of Fixtures: 2-
10 Applicant Name Street Address
11 Zip City State Phone
( )
*
9 BarSink(s): Drinking Fountain(s): Floor Drain(s): / Washing Machine(s): /
10 Dsh Wshr(s): Garb Disp(s): Kit Sink(s):
/
Lndry Tray(s): i Sew Eject(s):
11 Urinal(s): Wtr Closet(s): Lav(s): «y� Shower(s): / Tub(s): / Bidet(s):
0 Other: Type; V-+
W
CC
D
I- 12 Waste/Grease Interceptor(s): 04
Il
U. 13 Sewer Y N Septic/Health No.:
O
cc
w
CO 14 Electric Water Heater(s): / Drains-Roof:
2
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 40 / C ) „
APPLICATION
OWNER OR AGENT A.- - .0 _ 1 L�� G� DATE t �` J
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