1985, 06-10 Permit App: 00005923 Plumbing Fixtures r
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's me (Last (First) (M) Department Use Only
1(,(, eGr' 1,,.)e- . Project No.
2 Project AddrNot Mailing Address) Space Zip
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3 City/Community State Subdivision/Plat Name
4 Assessor Parcel No. I Lot Block
(-/23
16 Co�actor Firm Street Address
17 Zip 17 Z D CityStatek _ . Phone _33 006 C.
18 Contact Person Be No. (/x/l Phone if different tthaann aabboove
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8
Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work: New A; Addition/Alteration E ; Replace/Repair ❑ Total Number V
of Fixtures: /
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): 7 Lav(s): 7...._ Shower(s): / Tub(s): / Bidet(s):
N Other: Type;
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2
D
I- 12 Waste/Grease Interceptor(s):
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O 13 Sewer Y N Septic/Health No.:
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CO 14 Electric Water Heater(s): / Drains-Roof:
D
Z 15 REPAIR OR ALTERATION: Drainage,Vent,Water Piping/Treatment: Y N
16 Lawn Sprinkler System(s),including backf low device on any one meter:
17 Vacuum breakers or backflow devices in excess of line 16:1-5: (005+:
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 s ate of local laws regulating construction or the performance of
construction.
0/ (... /
SIGNATURE OF APPLICATION
OWNER OR AGENT a DATE ��