1984, 12-17 Permit App: 00003765 Plumbing Fixtures •
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's N�n , (Last) (First) (M) Department Use Only
/1,(r,pC�� Mailing
r - .4.0C . Project No.
2 Project Address pot Address) Space Zip
3 City/Community State Subdivision/Plat Name
4 Assessor Parcel No. I
Lot Block
376
16 Cor2.trAt.pr Firm Name Str t Address
vl►.,,.. 1 �rk4., e4--11 . Kb. vox G9/
17 Zip 1 City State Phone
1 ' 02 .Z a pi,kg—4U Itlif, ( Ls-3:5-ao4�
18 Contact Person u License No. Phone if different than above
IJ /M/RPi/ /4,02 Tr- 39-19
8 Owner/Agent(if different than 41 above) Business Address
9 Zip City State Phone
( )
15 Describe Work: New Jilt ; Addition/Alteration ❑ ; Replace/Repair ❑ Total Number
of Fixtures: /A
10 Applicant Name Street Address
11 Zip City State Phone
( )
* a I *
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): Sew Eject(s):
) Closet(s): ( ) 3 ) ( ) 2 ( )
11 Urinal(s: Wtr Lav s: Shower(s: Tub(s): Bidets
Other: Type;
W
CC
D
X12 Waste/Grease Interceptor(s):
U-
LL
O 13 Sewer Y N Septic/Health No.:
Cc
W
03 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 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 /a //74r1
OWNER OR AGENT DATE