1985, 07-15 Permit App 00006399 Plumbing Fixturese
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last)
f^ I A,C-AL t1C
(First) (M)
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Department Use Only
Project No.
2 Project A5dress (Not Mailing Address)
1—. 1 C-12/ Di--, -C- c ,
Space Zip
3 City/Community
State
Subdivision/Plat Name
4 Ase' - or Parcel No.
Lot
Block
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or Firm ame
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Street Address
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17 Zip
I City
State t1
,,.
Phone
18 Contact Person I
LicNo.
Phone if different than above
,J( A/ ;?P/-i 1 6a.J ..T
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
I State
Phone
( 1
15 Describe Work: New ; Addition/Alteration ❑ ; Replace/Repair ❑
t'
Total Number
of Fixtures: ��
10 Applicant Name
Street Address
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):
WtrCloset(s): 3
Lav(s): (8
Shower(s):
Tub(s): /
Bidet(s):
Other: Type;
12 Waste/Grease Interceptor(s):
13 Sewer Y N Septic/Health No.:
14 Electric Water Heater(s): t
Drains -Roof:
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 provisigrts oj-any other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
APPLICATION 7
DATE
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