1985, 03-11 Permit App: 00004414 Plumbing FixturesPLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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1 Owner's Name La61) / (Fir t�(M)
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Department Use Only
Project No.
2 Project Address (Not Mailing Address) / Space Zip
2,04 -Oe C Sea
3 City/Community I State
Subdivision/ Plat Name
4 Assessor Parcel No. I
COG1
Lot
Block
16 Contractor Firm Name
Gold Seal Mechanical
Street Address
13203 E Forrest
17 Zip
qq716
eeIrnc
Gt4
'P
ane
State
Wa
Phone
( 509) 924 3423
18 Contact Person
R Dixon
License No.
GO LD SM 290 C4
Phone if different than above
8 Owner/Agent (if different than PI above)
Business Address
9 Zip
City
State
Phone
( )
15 Describe Work: New Addition/Alteration 0 Replace/ pair G
Total Number
of Fixtures: ?O
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
9 Bar Sink(s):
Drinking Fountain(s):
FloorDram(s): .1—
Washing Machine(s): Z-
10
10 Dsh Wshr(s)'
Garb Dlsp(s):
Kit Sink(s).
Lndry Tray(s). , I Sew Eject(s):
11 Urinal (s):
Wt Closet(s):1.--(
Lav(s): U
Shower(s): 2
I Tub(s)
Bidet(s)
Other: Type;
12 Waste/Grease Interceptor(s):
13 Sewer Y N Septic/ Health No.:
14 Electric Water Heater(s): a-
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 18:1-5'
(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 3—c( -5