1986, 07-11 Permit App: 00012092 Plumbing Fixtures • lY/
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
IProject#
Owner's Name LL�astt /First MI
Project Address(Street Name&Naber)
6- /66- i --'' C.�.1��C e..ei4
CitySni. State // Subdivision t Name
AssesrsParcel# Lot Block Plat#
Applicant Address
City I State Zip Phone
Business Phone
�) i
Contractor � / , Addres _
City tIZZA.(4,466 Stat! ya
, d Zip Phone
Co � License# Business Phone
Describe Work
BarSink(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): WtrCloset(s): A Lav(s): A, Shower(s): Tub(s): Bidet(s):
y Other: Type;
W
CC
7
I- Waste/Grease Interceptor(s):
U-
u- Sewer Y N Septic/Health No.:
O
CC
W
CO Electric Water Heater(s): Drains-Roof:
2
7
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 Iine 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 state of local laws regulating construction or the performance of
construction.
SIGNATURE OF J APPLICATIO
OWNER OR AGENT C1tt,„ DATE 7/f/SYi6