1985, 1-16 Permit App: 00009441 Plumbing Fixtures PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
I Project# 'W/
Owner's Name �____....-- Lastf, First Ml
/ < er
Pe.- \--- I.—Ar ,
Project Addr s(Street Na Number) C )
City
State Subdivision/Plat Name
Assessors Parcel# Lot Block Plat#
Applicant Address
City I State Zip Phone
Business Phone
Address.)-` � vt., c..c,r''1�._- P4-41 l : i) i ?r K , ..69/
cit �/ State 1 Zip / Phone
ContBLt License# Business Phone
14N 'PN / ..
Describe Work %._.-4,.. I
Bar Sink(s): Drinking Fountaln(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): 3 Lav(s): Shower(s): / Tub(s): / Bidet(s):
y Other: Type;
W
cc
n
I- Waste/Grease Interceptor(s):
LL
W Sewer Y N Septic/Health No.:
O
OC
W
CCI Electric Water Heater(s): J Drains-Roof:
n b
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 o -ny ther state of local laws regulating construction or the performance of
construction. ,
/ /
SIGNATURE OF 1 1--
\ APPLICATION -"—
OWNER OR AGENT �[
a .—t DATE // /c4)