1985, 03-21 Permit App: 00004594 Plumbing Fixtures 4 r , 0
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A- PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
IProject N .4...;(1,,i,
Owner's Name Last First MI l�"I
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Project Address(Street Name&Number)
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Ci State Subdivision/Plat Na a .n
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Assessors Parcel 8 Lot Block Plat M
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AN. ;tds
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City I(Stat Zip Phone
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Business Phone
Contractor Address
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City / n State Zip Phone
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Co tact License N f Business Phone
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Describe Work
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BarSink(s): Drinking Fountain(s): Floor Drain(s): Washing Machine(s): /
Deli Wshr(s): Garb Diap(s): Kit Sink(s): Lndry Tray(s): Sew Eject(s):
L
Urinal(s): WtrCloset(s): z Lav(s): 2 Shower(s): / Tub(s): / Bidet(s):
co Other: Type;
W
CC
0
XWaste/Grease Interceptor(s):
LT
O
Sewer Y N Septic/Health No.:
CC
W
MElectric Water Heater(s): / Drains-Roof:
D
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: (00 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 41.0 ! i APPLICATIO ,
OWNER OR AGENT ' ' DATE !/1,/-,2 2 / 0---S-