1984, 08-24 Permit App: 00001932 Plumbing Fixtures Two
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) (M) Department Use Only ,/C 3
vs (I, Project No.
2 Project Address(Not Mailing Address) Space Zip
113 /
3 City/Community I State Subd'vi on/Plat_ e_�
t)( / Lc e-)M, /Id
4 Assessor Parcel No. Lot Block /
2/5 Z— O /o 6 ( /1/' 1
16 Contract rrm N me Q , Street Address
Ifo - -'k" /3 0 3 - - .r.—,-C
17 Zip Ci State Phone
18 Contact Person / License No. Phone if different than above
1QlKpa/ ‘C.) c-e, Cy
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work: New ❑ ; Addition/Alteration ❑ ; Replace/Repair ❑ Total Number
of Fixtures: /6
10 Applicant Name Street Address
11 Zip City State Phone
• r
9 BarSink(s): Drinking Fountain(s): Floor Drain(s): Washing Machine(s):
10 Dsh Wshr(s): Garb Disp(s): Kit Sink(s): I Lndry Tray(s): Sew Eject(s):
11 Urinal(s): WtrCloset(s): Lav(s): yl Shower(s): I Tub(s): Bidet(s):
L.0 Other: Type; t
cc
X12 Waste/Grease Interceptor(s):
LL
LL' 13 Sewer Y N Septic/Health No.:
O
M 14 Electric Water Heater(s): ( Drains-Roof:
2
Z 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 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 APPLICATION�T2.
OWNER OR AGENT DATE