1985, 03-15 Permit App: 00004589 Plumbing Fixtures•
V)
W
t—
X
T.
u_
0
CCw
2
z
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) (M)
/ \ 04 /c-(10 L,
Department Use Only
Project No. 4, etel
2 Project Address (Not Mailing Address) Space Zip
3 C.-21 c±ciL.. /7
3 City/Community
I State
Subdivision/Plat Name
4 Assessor Parcel No.
I Lot
Block
16 Contractor Firm Name
RIVER CITY PLUMBING INC.
Street Address
N 111 Vista Bldg. 7, D
17 Zip
99212
City
Spokane
State
Via.
Phone
( ) 924-8028
18 Contact PersonLicense
Audrey liobeck 1
No.
RIVERCP19OKA
Phone if different than above
8 Owner/Agent (If different than #1 above)
Business Address
9 Zip
City
State
Phone
( )
15 Describe Work: New ❑ ; Addition/Alteration 0 ; Replace/Repair ❑
Total Number
of Fixtures:
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
9 Bar Sink(s):
tDrinking Fountain(s):
Floor Drain (s): /
Washing Machines):
10 Dsh Wahr(s):
Garb Disp(s):
Kit Sink (ay
/
Lndry Tray (s):
Sew Eject (s):
11 Urinal(s):
WtrCloset k+Y
Lav(a):
Shower (s):
Tub(s):
Bidet(s):
Other: Type;
12 Waste/Grease Interceptor(s):
R`sµ
13 Sewer Y N Septic/Health No.:
14 Electric Water Heater(s): )
Drains -Root: YMAR 1 1985 j,l,.rr
15 REPAIRORALTERATION: Drainage, Vent, Water Piping /Treatment: Y N .Dept. of BUILDING
16 Lawn Sprinkler System(a), 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 -tate of local laws regulating construction or the performance of
construction. /)
SIGNATURE OF
OWNER OR AGENT
APPLICATION 7 ---
DATE 3 — /G `f J