1985, 07-24 Permit App: 00006611 Plumbing Fixtures F
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's ame (Last) (First) (M)
i / _ S_f Department Use Only
//Z/.-
� V7""'-- Project No.
2 Project Address(Not Mailing Address) Space Zip
.5-1l Z 2---O 01 etv/( A/
3 City/CommunityT Subdivision/Plat Name
C) 6 . e I State Us A ll
4 Assessor P rcel No. Lot Block
__ (&ems') I ( I ( �, r.
16 Contractor Firm Na e Street A/ddresss I-
17 ZipCit State Phone
9926�� I S`<'6 I — itie C,e)Al ( ) '92c6
18 Contact Person i License No. Phone if different than above
I d a/aLyc I 7—j--6E -11-z7lE
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City I State Phone
( )
15 Describe Work: New ; Addition/Alteration Elp p Re lace/Re air ❑ Total Number )(Z/
,1 �/ /
of Fixtures: / ^pc� (
10 Applicant Name Street Address ( ( (J
l6
11 Zip 'City State Phone
( )
*
9 BarSink(s): Drinking Fountain(s): Floor Drain(s): / Washing Machine(s):
10 Deh Wshr(s): / Garb Disp(s): Kit Sink(s): / Lndry Tray(s): / Sew Eject(s):
11 Urinal(s): Wtr Closet(s): Lay(s): Shower(s): Tub(s): Bidet(s):
-. / /
W Other: Type;
CC
D
X12 Waste/Grease Interceptor(s):
it
0 13 Sewer Y N Septic/Health No.:
CCW
Ca 14 Electric Water Heater(s): / Drains-Roof:
M
Z -
15 REPAIR OR ALTERATION: Drainage,Vent,Water PI ping/Treatment: Y N
16 Lawn Sprinkler System(s),including backflow device on any()Tie meter:
17 Vacuum breakers or backflow devices in excess of line 16:1-5: (Or)5+:
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. .,
r ex,...„..c.,Q
SIGNATURE OF
APPLICATION7/
z7 OQsOWNER OR AGENT /'/ DATE