1986, 05-08 Permit App: 00011059 Plumbing Fixtures 4
. , PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
5/i / 5Project#
f 1059
Owner's Name Last First MI
X��,moi-,Ci ,�/4dL=,L)
Project Ad_dress(Street Name&Number)
i/3o 6- //
City State Subdivision/Plat Name
C�� .0 i'" leil P 61
As essors Parcel# Lot Block Plat#
(L '3b)
.,Applicant Address
City I State Zip Phone
Business Phone
Address
Contractor P A/ IJA
k,-.=" 17 0, L? x
`D
City \J) 0 State Zip Phone/
`So Angi.- AiAs1l, 99 0 s - O04Z. .
Conikt
License# Business Phone
3014Ns3FI4 6,2-a,-3 E - 06 6,6
Describe Work o/UM ` y l U, p /0 / `x 7e'
r T` 6 DV% / Machine(s): /
BarSink(s): Drinking Fountain(s): Floor Drain(s): / Washing
Dsh Wshr(s): / Garb Disp(s): Kit Sink(s): / Lndry Tray(s): Sew Eject(s):
Urinal(s): Wtr Closet(s): Lav(s): Shower(s): / Tub(s): / Bidet(s):
W
Other: Type;
cc
n
XWaste/Grease Interceptor(s):
LL
tL Sewer Y N Septic/Health No.:
O
COCC
Electric Water Heater(s): Drains-Roof:
2
D
Z REPAIR OR ALTERATION: Drai lege,Vent,Water Piping/Treatment: Y N
Lawn Sprinkler System(s),including backflow device on any one meter:
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 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 to I laws regulating construction or the performance of
construction. 1/6 SIGNATURE OF APPLICATION OWNER OR AGENT DATEJ
7.,.,