1984, 05-16 Permit App: 00000301 Plumbing Fixtures I
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name
p (Last) (First) (M) Department Use Only
rerl TLC-
(2t , Project No. .�
2 Project Address(Not Mailing
drgss) Space I
Z/p
. / 7 —
3 City/Community I State Subdivision/Plat Name
14.4-4 Assessrcel No. I Lot Block
16 Contractor Firm Name Street Address
A[pave f)(kl�5`w� 'd 80,c zZ 3
• 17 Zip City State f Phone
18 Contact Per on I License No. Phone if different than above
a1-Ct(Mv✓ AI P i 41p // 3 ,b
8 Owner/Agent(if different than#1 above) Business Address
IN
C /`f7' S / 7{
9 Zip City State Phone
/4n 37 uet.4I.(c wo.-, Vdg ) V'7/
15 Describe Work: 4) New �; Addition/Alteration 0 ; Replace/Repair ❑ Total Number J +
of Fixtures: / o
10 Applicant Name Street Address
A tn./ SA.C.(c.,w,..) /1- 00C
11 Zip City State Phone
( 1
* *
9 Bar Sink(s): Drinking Fountain(s): Floor Drain(s): ( Washing Machine(s):
10 Dsh Wshr(s): Garb Disp(s): Kit Sink(s): / Lndry Tray(s): Sew Eject(s):
11 Urinal(s): Wtr Closet(s): 7 Lav(s): en; Shower(s): / I Tub(s): t Bidet(s):
U1 Other: �! Type; q( [CCC
l
U1 ( C
D
X 12 Waste/Grease Interceptor(s):
U-
U. 13 Sewer Y N Septic/Health No.:
O
CC
W
m 14 Electric Water Heater(s): Drains-Roof:
2
D
Z 15 REPAIR OR ALTERATION: Drainage,Vent,Water Piping/Treatment: Y N
16 Lawn Sprinkler System(s),including backflow device on any one meter:
17 Vacuum breakers or backflow devices in excess of line 16:1-5: (Or)5+:
45n 00
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 OR AGENT — DATE S //-27