1986, 07-17 Permit App: 00012152 Plumbing FixturePLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
240
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 DATE
APPLICATION
Project #
12/52.
..i
Owner's Name Last First MI
14/.4-7- L .t A il .,t/ r)
Project Address (Street Name & Number) ' 00 N+ e
City
',5f D/‹.A.A' C
State
WA
Subdivision/Plat Name , 1
ko 7 cm/�So.✓S ApPa-10 ../
Assessors^Parcel #
ids l — C, 7Z6
Lot
6
Block
1-
Plat #
Applicant
Ua�'po�✓ Lia
/fF1�
Address
Z. -,30,5- 1Jcoi, f,
City
sfi A 4 iv -C
State
L„.44
Zip
4 y 2. i z
Phone
c' z(r,- t 37
Business Phone
7 z6 -/378
Contractor
G= o r? as V D. f C/ L
Address
6. <$ o 5 ad0 ..,,,, e
City
S fLVc.. ,ri c
State
14-,A
Zip
i? 2 i Z
Phone
9 z. C' / 3 i'
Contact
License #
Business Phone
Describe Work
Bar Sink(s):
DrinkingFountain(s):
Floor Drain (s):
Washing Machine(s):
Dsh Wshr(s):
Garb Disp(s):
Kit Sink(s):
Lndry Tray(s):
Sew Eject(s): 1
Urinal(s):
WtrCloset (s):
Lav(s):
Shower(s):
Tub(s):
Bidet(s):
n Other: Type;
r
D
— Waste/Grease Interceptor(s):
K
i
i Sewer Y N Septic/Health No.:
D
r
L
n Electric Water Heater(s):
5
Drains -Roof:
D
Z REPAIR OR ALTERATION: Drainage, Vent, Water Piping/Treatment: Y N
Lawn Sprinkler System(s), including backflow device on any one meter:
Vacuum breakers or backflow devices in excess of line 16: 1-5:
(00 5+:
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 DATE
APPLICATION