1984, 09-25 Permit App: 00002485 Plumbing FixturesN ' PLUMBING PERMIT APPLICATION WORKSHEET
PLkASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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ry
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
CATION
DATE
OWNER OR AGENT DA
1 Owner's Nam% (last) (First) IMI Use Only
IDepartment
p
�Project No.
7
2 Project Address (Not Mallin dress) Space Zip
3 Gly/Community I
State
SubdNlel nl Plat Name
0 Assessor Parcel No:
I L t
Block
�.211135i
18 Contractor fir ay ///J
d�Gl /'�.[%
/� ��
Stree Address
x/70 7
on /4.49— /• /CK
a
17 Lp /‘'p
7 /1A/
City
State
/
Phone y�/�
I I V,�9 �l.Yv
18 Contact Person
I
License No.
Phone If different than above
6 Owner/Agent( If mfterent than 01 above)
Bust
ass Address
9 Zip
City
State
Pnone
1
15 Describe Work: New AddItlon/Altemtim ❑ Replace/Repair ❑
Total Number
of Fixtures:I -443
10 Applicant Name
pp
Scree Address
11 Zly
City
State
Phone
( I
9 Bar Sink(s):
Drink' g Fountaln(s):
Floor Oraln(s): /
Wash! gMachinelsl:
10 DM Wahr(s):
Garb Disp(s):
Kit SInkO: /
Lndry Tray(s):
Sew Eject(s):
11 tklnnfts):
Wt ClosetN): L
Lav(s): "L/
Shower(s):
I Tubbs): /
Bidega):
Other: Type;
12 Waste/Grease Interceptor(s):
13 Sewer Y N Septic/ Health No.:
14 ElectrlcWater Heater(s): /
pains -Root:
15 REPAIR OR ALTERATION: Dra)neae, Vent, Water Piping/Treatment: Y N
16 lawn Sprinklersystem(s). Including bacMlow device on any one meter:
17 Vacuum breakers or backflow devices In excess of line 16:15:
(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
CATION
DATE
OWNER OR AGENT DA