1985, 12-27 Permit App: 00009263 Plumbing Fixtures s
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
IProject# 3
Owner's Name i Last _• First MI
c'-97c_ _LA) •
Project Address(Street Na a Number)
City State Subdivision/Plat Name
Assessors Parcel# Lot Block Plat#
Applicant Address
City State Zip Phone
Business Phone
Contra arie
p
City State Zip Phone
ContacV Lis Phone
4e3/I ( gl /407 Business
Describe Work
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): 7 Shower(s): / Tub(s): Bidet(s):
N Other: Type; G---
W
2
XWaste/Grease Interceptor(s):
U-
W Sewer Y N Septic/Health No.:
O
C
CD Electric Water Heater(s): / 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: (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 a other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF . APPLICATION ---=
OWNER OR AGENT DATE ���� �J