1985, 05-13 Permit App: 00005375 Plumbing Fixtures • PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name
L� , (Last) (First) (M) Department Use Only
S 4 c•AN` .5 TA.
♦ , Project No.
2 Project Address(Not Mailing Address) Space Zip
d Cc oe) Iii-
L.
3 Cit /Communit State Subdivision/Plat Name
Y Y
No:-.)-- �..
4 Assessor Parcel No. Lot Block
16 Cogtra_ctor Fi5 / Street ddress
( f".. 7:3
•
17 Zip I City State Phone
teo
18 Contact Person License N/o. Phone if different than above
lot:te 42
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work: New 'A ; Addition/Alteration CI ; Replace/Repair ❑ Total Number
of Fixtures:
10 Applicant Name Street Address
11 Zip City State Phone
( )
* a «
9 Bar Sink(s): Drinking Fountain(s): Floor Drain(s):
/
Washing Machine(s): f
10 Dsh Wshr(s): Garb Disp(s): Kit Sink(s): / Lndry Tray(s): Sew Eject(s):
11 Urinal(s): Wtr Closet(s): Lay(s): �j Shower(s): Tub(s): / Bidet(s):
N Other: Type; 4"
W
CC
D
X12 Waste/Grease Interceptor(s):
LL
LL'
O 13 Sewer Y N Septic/Health No.:
CC
W
m 14 Electric Water Heater(s): i Drains-Roof:
2
7
Z 15 REPAIR OR ALTERATION: Drainage,Vent,Water Piping/Treatment: Y N
16 Lawn Sprinkler System(s),including backf low 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 , j� , _ APPLICATION c
OWNER OR AGENT // DATE �'� O J