1985, 10-16 Permit App 00008105 Plumbing FixturesPLUMBING PERMIT APPLICATION WORKSHEET
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PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) (M)
Department Use Only
Project No. j [ 0
2 Project Address (Not Mailing Address) Space Zip
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3 City/Community
I State
Subdivision/Plat Name
4 Assessor Parcel No.
I Lot
Block
16 Contractor Firm Name
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Street Address
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17 Zip
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City
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State
Glio�
Phone
( ) %'.o*'G ���
18 Contact Person
License No.
Phone if different than above
8 Owner/Agent (if different than #1 above)
Business
Address
9 Zip
City
State
Phone
( )
15 fl scribe Work: New C4-1-- Addition/Alteration ❑ ; Replace/Repair ❑
Total Number
of Fixtures:
10 Applicant Name
Street Addr
11 Zip
29�a 2
City i
7�,� e
State
GC--, r
Phone
( ) 7?7 s�Q��.--
9 BarSink(s):
Drinking Fountain(s):
Floor Drain (s): .�
Washing Machine(s): 2
10 Dsh Wshr(s):
Garb Disp(s): 7
Kit Sink(s): R
LndryTray(s):
Sew Eject(s):
11 Urinal(s):
WtrCloset(s): 6
Lav(s): (<i
Shower(s): 2
Tub(s): d-?
Bidet(s):
Other: Type;
12 Waste/Grease Interceptor(s):
13 Sewer Y N Septic/Health No.:
14 Electric Water Heater(s): ,2,7
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 provisions of any other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
APPLICATION
DATE
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