1986, 06-06 Permit App: 00011436 Plumbing Fixtures PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
IProject# 4 2
Owner's Name Last First MI J
I Of l4 c, . OP Ks
Project Address(Street Name&Number) / I, 1/7 C / / fC
City State 5`[ (� Subdivision/PlatvilName
Assessors Parcel# Lot Block Plat#
(,1 / L/g)
Applicant Address
City I State Zip Phone
Business Phone
Contractor Address
City I State Zip Phone
Contact License# Business Phone
Describe Work
Bar Sink(s): Drinking Fountain(s): Floor Drain(s): l Washing Machine(s): /
Dsh Wshr(s): Garb Disp(s): I Kit Sink(s): / Lndry Tray(s): Sew Eject(s):
Urinal(s): WtrCloset(s): I Lav(s): y Shower(s): f Tub(s): / Bidet(s):
° Other: Type;
W
I- Waste/Grease Interceptor(s):
X_
LL
LL Sewer Y N Septic/Health No.:
O
03 Electric 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: (00 5+:
/45-44
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 6- `-
OWNER OR AGENT - DATE