1985, 02-04 Permit App: 00004087 Plumbing Fixtures, Woodstover
"w~w�< PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owners Name (Last) (First) (M)
Department use Only
Project No.
2 Project Address(Not Mailing Address) Space Zip
3 City/ Community
I State
SubdivIeI n/Plat Name
d Assessor Parcel No.
I Lot
Block
Dgi
16 Contractor Firm Name
Street Address
17 Zip
City
State
Phone
1
18 Cont(ePerson
I License No.
Phone 11 different than above
8 OwnerlAgent (If ditierent than 111 above)
Busi
ess Address
9 Zip
City
I State
Phone
( )
15 Describe Work: New .e‹
Addition/Alteration 0 ; Replace/Repair El
Total Number q
of Fixtures:
10 Applicant Name
Street Address
11 Zip
City
State
Phone
(
9 Bar Slnk(s):
Drinking Fountain Is):
Floor Draln(s):
Washl g Machin,): /
10 Doh Wshr(a):
Garb Dlsy(q:
KIt SInk(s): /
LntlrYTr y(s):
Sew Eject(s):
11 Urinal 41:
WI Closet(s): r
Lavh): #2,,,,,
I Shower(s): / I
Tub(s): /
Bidet l5):
Other: Type;
12 Waste/Grease lnterceptor(e):
13 Sewer Y N Septic/ Health No.:
10 Electric Water Heater(s): /
Drelne-Root
15 REPAIR OR ALTERATION: Drainage, Vent, Water Piping/Treatment: Y N
16 Lawn Sprinkler System(s), Including backflow device on anyone meter:
17 Vacuum breakers or backflow devices In excess of line 16:1-5:
I I -
(Or)5+:
Go tile 77ve, 24.
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
APPLICATION
DATE
04,