1985, 07-01 Permit App: 00006237 Plumbing Fixtures PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name,- (Last) (First) (M) Department Use Only
.-----,-
Iu --Li I-sC•; Project No.
2 Project Address(Not iI g Address) Space Zip
C' t-)7 Ix."/97 7'CCCCL" _ - /�: - =
3 City/Community State Subdivision/Plat Name
4 Assessor Parcel No. I Lot Block
65-7q1/7)
7 �) X231
16 Conitraetor Firm Name Stmt Address
—JC I,>,t. i�Lcr-,4e .- , . c 26 cl
17 Zipf City State Phone
9 -e� , .,.k ( 47 _
18 Contact Person V Licen No. Phone if different than above
p 8 Owner/Agent(if different than#1 above) ' Business Address
9 Zip City State Phone
( )
15 Describe Work: New ; Addition/Alteration ❑ ; Replace/Repair ❑ Total Number
' /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):j
10 Dsh Wshr(s): Garb Disp(s): Kit Sink(s): / Lndry Tray(s): Sew Eject(s):
11 Urinal(s): Wtr Closet(s): Lav(s): 27 Shower(s): / I Tub(s): / Bidet(s):
W
Other: Type; / l
IX
X 12 Waste/Grease Interceptor(s):
LI
LL
O 13 Sewer Y N Septic/Health No.:
Cr
W
m 14 Electric Water Heater(s): / Drains-Roof:
2
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+:
6 2—
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 if any other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF . _ APPLICATION / r,>
OWNER OR AGENT - lel e_(-' _ DATE /