1985, 10-31 Permit App: 00008503 Plumbing Fixtures • PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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I Project# 36.63
Owner's Name Last t_ First MI
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Project Address(Street Name mbar)
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City State Subdivision/Plat Name
Assessors Parcel# CO
��+ Lot Block Plat#
Applicant Address
City State Zip Phone
Business Phone
CQL11Facti5i Ad ess
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City I State ,. Zip Phone
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Cont4L1 f Licen # Business Phone
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Describe Work f .
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BarSink(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): WtrCloset(s): —7 Lav(s): 7 Shower(s): / Tub(s): / Bidet(s):
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W ( (
w Other: Type;
CC
XWaste/Grease Interceptor(s):
U-
LL' Sewer Y N Septic/Health No.:
O
C
W
CO Electric Water Heater(s): r� Drains-Roof:
2
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 -ny other state of local laws regulating construction or the performance of
construction.
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SIGNATURE OF APPLICATION / / /7(
OWNER OR AGENT �7� ��/ / DATE �C/ �,�1j