1985, 02-28 Permit App: 00004330 Plumbing Fixtures a -
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's NamJ,�.. (Last) (First) (M) Department Use Only
.s'
Iti., 0e,r. ,.. Project No.
2 Project Address(Not liailing Address) -� ., Space Zip
off• fg 71 2 lC r clw or,r,_w-) ='' KeL
3 City/Community State Subdivision/Plat Name
4 Assessor Parcel No. I Lot Block
Vs. ac)
16 Contr Firm Name ' Street Address
17 ZipCity State ,t Phone
9 9 �5,l k :, - �c.j, :s-� -mit
18 Contact Person License No. Phone if different than above
7/Ngp,4 / ,iJ
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City I State Phone
( )
Total Number 'l
15 Describe Work: New x ; Addition/Alteration 0 ; Replace/Repair ❑ `� r ���
of Fixtures: [
10 Applicant Name Street Address
11 Zip City State Phone
( )
* *
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):
11 Urinal(s): Wtr Closet(s): - Lav(s): � Shower(s): / Tub(s):
/
Bidet(s):
co Other: Type;
W
CC
7
X12 Waste/Grease Interceptor(s):
LL
0
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 provision of -ny other state of local laws regulating construction or the performance of
construction. .
SIGNATURE OF / . / APPLICATION -�/
OWNER OR AGENT T.' -- DATE ✓' ' ` �
i