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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,