1985, 07-22 Permit App: 00006568 Plumbing Fixtures PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name f (Last) (First) (M) Department Use Only
/_ Pe„ �u�J Project No.
2 Project Address(Not Maill/mig ddress) Space Zip
1371D
3 1-City/CommunityState Subdivision/Plat Name
4 Assessor Parcel No. 1 Lot Block ._ 65–f6g
r
ame
1 J LotwmN�I Kra / �7 4 L S1! • ,res?o>C. .0.7 ,>/ _
17 Zip City State Phone
??t,Z02D :o k� �.� ( ),...5 gs=DDGG
18 Contact Person License No. Phone if different than above
-,L,fM77Pt1 /6.7—1 J
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work: New K; Addition/Alteration ❑ ; Replace/Repair E Total Number
of Fixtures:
10 Applicant Name Street Address
11 Zip City State Phone
( )
* *
9 BarSink(s): Drinking Fountain(s): Floor Drain(s): / Washing Machine(s):,
10 Dsh Wshr(s): Garb Disp(s): Kit Sink(s): /
Lndry Tray(s): I Sew Eject(s):
11 Urinal(s): Wtr Closet(s):.2 Lav(s): Shower(s): / Tub(s): ( Bidet(s):
U) Other: Type;
W
CC
0
I- 12 Waste/Grease Interceptor(s):
LL
LL
O 13 Sewer Y N Septic/Health No.:
OC
W
Ca 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+:
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 OF111119
j APPLICATION7%...z../§f5
OWNER OR AGENT .s:.. _; _ DATE