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1985, 03-11 Permit App: 00004411 Plumbing Fixtures• d PLUMBING PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND 1 Owner's Name Last) (First) (M) 1 Department Use Only �'- Project No. 2 Project Address (Not Mailing Address) pace Zip go3-©s EAP 3 City/Community State Subdivision/Plat Name 4 Assessor Parcel o. 1 Lot Block 16 Contractor Firm Name Gold Seal Mechanical, Inc Street Address 13203 E Forrest 17 Zip 99216 City Spokane State Wa Phone ( 509) 924 3423 18 Contact Person R Dixon License No. GO LD SM 290 C4 Phone if different than above 8 Owner/Agent (If different than *1 above) Business Address 9 Zip City State Phone ( ) 15 Describe Work: New CI(; Addition/Alteration ❑ ; Replace/Repair ❑ Total Number of Fixtures: aQ 10 Applicant Name Street Address 11 Zip City State Phone ( ) 9 Bar Sink(s): Drinking Fountain(s): Floor Drain(s): Washing Machine(s): 10 Dah Wshr(s): Garb Disp(s): Kit Sink(s): rL� Lndry Tray(s): Sew Eject(s): 11 Urinal(s): WtrCloset (s): st Lav(s): ( Shower(s): 2 I Tub(s): _. Bidet(s): Other: Type; 12 Waste/Grease Interceptor(s): 13 Sewer Y N Septic/HealthNo.: 14 Electric Water Heater(s): Z 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: (00 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 ,Zo�Y ate, APPLICATION3�`�� Fr -5 DATE