Loading...
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 �-ri q 77 4' ,/) J p 1� �1 sk;7�� 52-- 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 e ;i/y erg 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