1984, 08-17 Permit App: 00001862 Plumbing FixturesPLUMBING PERMIT APPLICATION WORKSHEET as
PLEASE PRINT AND COMPLETE ONLY THOSE P RTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) ' (M)
Department Use Only r�31�r
%�
Go 1 d0 e'✓,_ Cv-A S T
� �-T Gf
Project No.
2 Project Address (Not Mailing ddress) ` Space ZIP
S,�//)(3 Z..4-20,0 1"-›
3 City/Community
State
Subdivision/Plat Name
c.1
4 Assessor Parcel No.Lot
25c-/1- lib
1
Block
I
.:,.
16 Contractor Firm Name
KT-, (- C .
Street Address
/g-ZV IV 4s IA
17 Zip
92-C) /
City
Srp 4_3
State
(.,t)v->;
Phone
( ) 3-.2-6 -S60 6
18 Contact Person
License o.Phone
()/lL
E 762 ,&e.
if different than above
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
State
Phone
( )
15 Describe Work: New ' Addition/Alteration E ;
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): /r
10 Dsh Wshr(s): ,/
Garb Disp(s):
Kit Sink(s):
/
Lndry Tray(s): /
Sew Eject(s):
11 Urinal(s):
WtrCloset(s): . 7
Lay (s): ,: 1 Shower(s): /
Tub(s): /
Bidet(s):
Other: Type;
• 12 Waste/Grease Interceptor(s):
i 13 Sewer Y CN) Septic/Health No.:
14 Electric Water Heater(s): /
Drains -Roof:
' 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 Cat 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
OWNER OR AGENT
APPLICATION
DATE' -/ 7- t