1986, 05-07 Permit App: 00010772 Plumbing FixturesPLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
I Protect M
107
07 7 2_
Owner's Name Last First MI
Fi/idAI.-gyq ge-17,475
Project Address (Street Name & Number)
7 7o Ss C
W
City
State
Subdivision/Plat Name
Assessors Parcel It,�`
1073-7 l
Lot
Block
Plat #
Applicant
Address
City I
State
Zip
Phone
Business Phone
Contractor
Gold Seal Mechanical Inc
Address
5524 E Boone
City 1 State
Spokane Wa
Zip
99212
Phone
509 535 5944
Contact
R Dixon
License It
GO LD SM *290 C4
Business Phone
Describe Work
SFR
Bar Sink(s):
Drinking Fountain (s):
Floor Drain (s): f
Washing Machine(s): /
Dob Wshr(s):
Garb Diap(s)'
Kit Sink(s): /
Lndry Tray(s):
Sew Eject(s):
Urinal(a):
WI Closet(s): 2
Lav(s): Z
Shower(s)' /
Tub(s): /
Bidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer Y N Septic/Health No.:
Electric Water Heater(s):
Drains -Roof:
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:
(04 5+:
/D_v YO
/S—
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. �, 1
SIGNATURE OF
OWNER OR AGENT
APPLICATION
DATE ?—"IrC