1985, 08-20 Permit App: 00007008 Plumbing Fixtures1.
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Project # V S
Owner's Name Last , First MI
Project Address (Street Name & Number)
S• 4-dZ0 w bq .r u -FC
City
LA—IL./
State
L.L)a61^-,
Subdivision/Plat me
4 L f`o5d # S
Assessors Parcel #
Lot
3Applicant
Block(
Plat #
ice C,,
t H --b
Address
I / I. b f. 4f
CityState
,,14;1v42.
G—.06 ..
Zip
'7Z��
Phone
�Z7-g0 a i
ti�
Business Phone
5. W‘sil....,
Contractor
C--> I. liaa- C.,00. i -r u..4% 0 \..o s2,ry tc S ,- ,mac .
Address
BGC i 4 14 Z-4
City
-5p6kal
1 State
--)...
Zip
, q Z1 i -t-
9 Z- 8 J s Z,
Contact
V* 1. k.e, i
License #
fj I. 1...3L."... s zo36I
Business Phone
5.a w.51.,
Describe Work
_
Bar SInk(s): Jo
Drinking Fountain(s): 4
Floor Drain(s): 0
Washing Machine(s): 1
Dsh Wshr(s): I
Garb Disp(s): '
Kit Sink(s): '
Lndry Tray(s):0I
I
Sew Eject(s):
Urinal(s): 0
Wtr Closet(s): 3
Lav(s): L� ,
T
Shower(s): ii
Tub(s):
Bidet(s): 56
Other: �oI Type;
Waste/Grease Interceptor(s): 'LA041 1.47./
Sewer Y O Septic/ Health No.:
Electric Water Heater(s): I
Drains -Roof: 5+
REPAIR OR ALTERATION: Drainage, Vent, Water Piping /Treatment: Y d
Lawn Sprinkler System(s), including backflow device on any one meter:
7
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 provisions of any other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT V l Ic%�•
APPLICATION $ _ _
DATE