1985, 05-28 Permit App: 00005699 Plumbing Fixtures • PLUMBING PERMIT APPLICATION WORKSHEET Colo•00
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner'sNa� (Last) (First) (M) Department Use Only
/f'ie- to rte- Project No.
2 Project Address( of ailing Address) Space Zip
. i • /'/?a7 V 6062.4sit r
3 City/Community I State Subdivision/Plat Name
4 Assessor Parcel Noe, zio
/ Lot Block '5/Q
16ntFirm N Street Addre
.t, .c..t-k — f-# P,R . .„7c/17 Zip I City State Phone
710.1,00 ic_
18 Contact Person . 65-171/1/RP171
nse No. Phone if different than above
/tea? J
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work: New A; Addition/Alteration 17 ; Replace/Repair ElTotal Number Y
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 Deh Wshr(s): / Garb Disp(s): Kit Sink(s):
/ Lndry Tray(s): Sew Eject(s):
11 Urinal(s): WtrCloset(s):2 Lav(s): I Shower(s): / I Tub(s): Bidet(s):
Other: Type;
W
J
CC
D
X 12 Waste/Grease Interceptor(s):
LI
W
O 13 Sewer Y N Septic/Health No.:
CC
W
CO 14 Electric Water Heater(s): / Drains-Roof:
2
m
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 • -ny • her state of local laws regulating construction or the performance of
construction.
SIGNATURE OF APPLICATION �/27,43 ' -
OWNER OR AGENT ,: / . ,. _ '� DATE "