1985, 02-13 Permit App: 00004138 Plumbing FixturesN
W
f—
X
IJ_
LL
O
ccW
m
Z
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1
Owner's Name (Last)
(First)
(M)
Department Use Only
Project No.
2
Project Address (Not Mai IiAddress)
O D61-75�1-
Space Zip
3
City/Community
State
Subdivision/ Plat Name
4
Assessor Parcel No.
Lot
Block
%
16
ntractor Firm Name
1U DL. p -� sc- %
Street Address
Hell -3
17
Zip
City
State
Phone
(9 ) Al 7_3
18 Contact Person
License No.
P
L 0Iq
Phone if different than above
6 Owner/Agent (if different than #1 above)
Business Address
9
Zip
City
State
Phone
15
Describe Work: New ❑ Addition/Alteration
❑
Replace/Repair ❑
7-
Total Number
of Fixtures: %
10 Applicant Name
Street Address
11
Zip
City
State
1 Phone
( )
9
Bar Sink(s):
Drinking Fountaln(s):
Floor Drain(s): /
Washing Machine(s): 1
10
Dsh Wshr(s): )Garb
Disp(s):
Kit Sink(s): `
Lndry Tray(s):
Sew Eject (s):
11
Urinal(s):
Wtr Closet (s):
v�
Lav(s):
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):
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 APPLICATION �`�
OWNER OR AGENT DATE
41a'
I am requesting a temporary Certificate of Occupancy be issued for
5,-o€NC'c located at N -T K-) rnOct -r tA
for a peri od ofcommenc-
i ng and ending .S)4_
�S
Reasons for request:
JiE('—, -C P_ Z) C72KiO�NG� Arwc,iN
2 L�j"RG\"0R" S"cC'•'S 2 r�41av1�2FtIL"� Lt(-3tZi��AiL�� �-QUf' �C�prlG<E �G
e}- �Cz.yy,iiv•-�r�,� u�i�0• ! F012 +�'-f
I am aware that failure to comply with the above-mentioned conditions
of this temporary Certificate of Occupancy may result in revocation
of the Certificate and as a consequent, I could be charged with a
misdemeanor and be subjected to the penalty provisions contained in
Title 3 of the Spokane County Code which specifically states:
"3.02.070 Violation - Penalty. Pursuant to Section 205
of the 1979 edition of the Uniform Building Code, Section
20.3 of the 1979 edition of the Uniform Plumbing Code,
Chapter 3.09 (Mobile Homes) and in replacement of the
penalties set forth in Section 202 of the 1979 edition of
the Uniform Mechanical Code, the violation of any of the
provisions of this Title shall be a misdemeanor and shall
be punishable, upon conviction, by a fine of not more than
five hundred dol l ars ($500.00), or by imprisonment for not
more than ninety (90) days, or be both such fine and
imprisonment. With the exception of the above described
penalty provisions, the sections of the uniform codes
enumerated herein shall remain in full force and effect."
wner/s SL n t u r "
on r for s i g to"re
Da e
to
an and for the
State o,f Washington;, residing
at, SDok.a'ne.