1985, 07-08 Permit App: 00004863 Plumbing FixturesPLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1
Owrrer'e Nemo t) (FIW)
oProject
(M)
Oepa"noart Uea Only
No.
2
Prokot Ackin, Mot Melling Adds) Space
Zip
Zip
3
City/(bmmunity
0 LG9�'e
SIN�e� /� p J
Wcr /l
6uEdIVIe1m IPlel Name
a
Assisi aknow No
�.3'1C2
Lot
Blmk
� X63
18 Canlrslp Flrm a
EAI fie, 0 rciP SNC,
Slreet Address
11607 eAtl
ti
ZID C? ^ ��
`�7
City .�
Slate
Rlpne
,B Cannot Pe �
LI[eneaJ—�G —/[�-2
�/�
�j
31eL
Pl,nnaB'"anan111an eCove
8 Oaner/Agrlt(BdlfferenttWnel Wove)
9WIness Address
9
ZIp
City
Stale
I Klan
( 1
15
yy
CeecrlW Work: New cn; A,kitlonlAltendion ❑ ; RepILLV/Repair ❑
Total Number ,�,.
Of FIKWrs: A
10 Applicant Name
avast Address
11
➢p
01W
State
Mons(
1
9
Br Slnkp):
dlnkWg Foun4lnle):
Flopdalnlq:
Wuhing MxnI-N): /
10
CM Mhrlp:
Gert, 01i
Kit Blnklel:
Lndry T,,(.):
Sen Pdxrye):
11
Vinal(a):
Mr Cloki
—0):
ShdwpP):
Tubo): /
BIdM(al:
oMr: Tyga:
12
NWB/Gmiselntemator(e):
13
fnwr Y N No.:
1/
/Septic/Health
EhkArlcWatr HMr(el: /
[[
Rr:
damsro
15
REPAIR OR ALTERATION: Ogtim0a, Vent, Watar PIPIN/TrMimenL Y N
16
lawn Sprinklrbyelem(e),InclWingb Ulpwdwicemanyonameter:
17
Vewum beakerew SakBawdevtoss In ercwMIIM 18:1-$:
(ar15�:
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 t rk, including inspection requirements, will be com-
plied with whether specified herein or a granting o a permit does not presume to give authority to
violate or cancel the provisions o er s aregulating construction or the performance of
construction.
SIGNATURE OF DATE ATIOfJ z
OWNER OR AGENT ��C DATE.l/
/�T