1984, 09-18 Permit App: 00002484 Plumbing Fixtures a
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'w" • PLUMBING PERMIT APPLICATION WORKSHEET
, PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's ame (Las) (First) (M) Department Use Only
`l ! C-'mss J Project No.
2 Project Address(Not ling Address) Space f Zip
3 City/Community State Subdivision/Plat Name
4 Assessor Parcel No. I Lot Block
b 16 Contractor Fir a e �f/ Street Address 7
atetevief
17 Zip Ci State Phone At
18Contact Person License No. Phone if different than above
(4 I1LP8q
& f.2
8 Owner/Agent(if different than N1 above) Business Address
9 Zip City State Phone
-� 1 ( )
V 15 Describe Work: New a„,-,..---- Addition/Alteration ❑ ; Replace/Repair ❑ Total Number
w� of Fixtures:
M'V 10 Applicant Name Street Address
11 Zip City State Phone
( )
* 1 *
9 BarSink(s): Drinking Fountain(s): Floor Drain(s): / Washing Machine(s):
10 Dsh Wshr(s): Garb Disp(s): Kit Sink(s): / Lndry Tray(s): Sew Eject(s):
11 Urinal(s): Wtr Closet(s): Lav(s): Z—%._ Shower(s): Tub(s): ! Bidet(s):
u) Other: Type; i
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0
X12 Waste/Grease Interceptor(s):
LI
W 13 Sewer Y N Septic/Health No.:
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m 14 Electric Water Heater(s): / Drains-Roof:
2 r
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 OFAPPLICATION r�
OWNER OR AGENT 2�C -e-e-e, `� Z DATE //��j