1985, 04-29 Permit App: 00005209 Plumbing Fixtures •
PLU BING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND C MPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) (M
G--e./11, ('Tr ) Department Use Only
2 Project Address(Not MailingAddress) 11�/lP 5 Project No.
Space Zip
3 City/ mu/ty ° d .-
lot State Subdivision/Plat Name
4 Assessor Parcel No. L
1 Block I
1 45;74 C
16 Co Firm Name I Str t Address
, .� r,k.. a,1.rk� P44V- , D. go
17 Zip Citya �/
il./!AR_
o Phone
18 Contact Person •� � ��°i State ��' ( )S3.5 Q�cp�p
Li�sallo. Phone if different than above
8 Owner/Agent(if different than#1 above) I Business Address
9 Zip (City
State Phone
( )
15 Describe Work: New 711.; Addition/Alteration ❑ ; Replace/Repair ❑ Total Number
of Fixtures: /D
10 Applicant Name I Street Address
11 Zip I City State
I Phone
( )•
*
9 Bar Sink(s): I Drinking Fountain(s): Floor Drains
( ) I Washing Machine(s):
10 Dsh Wshr(s): / I Garb Disp(s): I Kit Sink(s): ' I LndryTray(s):
I Sew Eject(s):
11 Urinal(s): I Wtr Closet(s): A.,
I Lav(s): I Shower(s): / I /
( ) Tub(s): / I Bidet(s):
W Other: Type;
CC ID
X12 Waste/Grease Interceptor(s):
o 13 Sewer Y N
O Septic/Health No.:
ccW
m 14 Electric Water Heater(s): / I I
Drains-Roof:
Z 15 REPAIR OR ALTERATION: Drainag#,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:
(005+:
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 hereir 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
OWNER OR AGENT ,.�4 r .- / DATE '�