1986, 03-12 Permit App: 00010055 Plumbing Fixtures e4
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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I Project# //�'���**'}}
Owner's Name / 675-
Last /C.�( )55
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Project Address(Street am &Number)
City State �u ie.,e 6 C� p"i
I -C---C Subdivision/Plat Nam
Assessors Parcel#
Lot [Block
I Plat#
Applicant
Address
City I State
IZip Phone
Business Phone
ctor
Om Addr
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r'Cit {{�� State Zip Phone ' �[���
# Doi
Business Phone
Describe Work ��
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Bar Sink(s): I Drinking Fountain(s): Ir
Floor Drain(s): Washing Machine(s):
Doh Wshr(s): I Garb Disp(s): I Kit Sink(s): I
Lndry Tray(s): I Sew EJect(s):
Urinal(3): I WtrCloset(s): I Lav(s): J
I Shower(s): / I Tub(s):
I Bidet(s):
W Other: Type;
CC
0
I- Waste/Grease Interceptor(s):
U-
LL
Sewer Y N Septic/Health No.:
cc
lL
COElectric Water Heater(s): /S
Drains-Roof:
Z REPAIR OR ALTERATION:
Drainage,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+:
55
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
APPLICATION
OWNER ORAGENT _o /r _ DATE ,�� 4/ ''