1986, 03-12 Permit App: 00010056 Plumbing Fixtures • PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
IProject#
Owner's Name _— Last First MI
Project Address(Street ry3 e 1
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City State •C--�f'� Subdivision/Plat Name
Assessors Parcel# Lot Block Plat#
Applicant Address
City I State Zip Phone
Business Phone
City SSS tate Zip Phone
Lice # Business Phone
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Describe Work
0 T'f x4„,
BarSink(s): Drinking Fountain(s): Floor Drain(s): / Washing Machine
Dsh Wshr(s): Garb Disp(s): Kit Sink(s): / Lndry Tray(s): Sew Eject(s):
Urinal(s): WtrCloset(s): Lav(s): Shower(s): / Tub(s): / Bidet(s):
N Other: Type; /
W
CC
XWaste/Grease Interceptor(s):
U-
LL Sewer Y N Septic/Health No.:
O
CCW
COElectric Water Heater(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 APPLICATIONC-FA-7 t
OWNER OR AGENT ilk . ■11i A.. _ 1a ) .c _ DATE