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1986, 02-10 Permit App: 00009654 Plumbing FixturesN W cc 1- 1— X X tL 0 ccW m 2 Z PLUMBING PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND I Project # LI/ 5 !`(/I Owner's Name Last First MI 0-i 9 Bve4Oc'cS Project Address (Street Name & Number) U' . goC A c c 655AV City State Subdivision/Plat Name Assessors Parcel # Lot Block Plat # Applicant Address City I State Zip Phone Business Phone Contractor Gold Seal Mechanical, Inc Address 5524 E Boone CftyState Spokane I Wa Zip 99212 Phone 509 535 5944 Conte R Dixon License # GO LD SM *290 C4 Business Phone Describe Work SFR BarSink(s): Drinking Fountain(s): Floor Drain (s): ( Washing Machine(s): / Deh Wshr(s): Garb Disp(s): Kit Sink(s): Lndry Tray(s): Sew Eject(s): Urinal (s): Wtr Closet (8): Z Lav(s): Z Shower(s): / 1 Tub(s): / Bidet(s): Other: Type; Waste/Grease Interceptor(s): Sewer Y N Septic/ Health No.: Electric Water Heater(s): 1 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 18:1-5: (00 5+: `t` -5-5-- 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 2— / ' • S'6