1986, 06-04 Permit App: 00011430 Plumbing FixturesN
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1Project X / III so
Owner's Name Last First MI
r Av,Sep ci
Project Address (Street Name 8 Number) / 3 d //
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City
State
Subdivision/ Plat Name
Assessors Parcel X
(/O -i&)
Lot
Block
Plat X
Applicant
Address
City
1 State
Zip
Phone
Business Phone
Contractor
Gold Seal Mechanical Tnc
Address
5594 F Entine
City 1 State
Spokane Wa
Zip
99212
Phone
509 535 5944
Contact
R Dixon
License X
GO LD SM *290 C4
Business Phone
Describe Work
SFR
Bar Sink(s).
Drinking Fountain(s):
Floor Drain(s): /
Washing Machine(s): I
Dsh Wshr(s):
Garb Disp(s):
ICS Sink(s):/
Lndry Tray(s):
Sew Eject(s):
Urinal(s):
Wt Closet(s): 3
Lay(s): _3
Shower(s): 2
Tub(s)• /
Bidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer V N Septic/Health No..
Electric Water Heater(s):
Drains -Roof:
REPAIR OR ALTERATION: Drainage, Vent, Water Piping/Treatment: V N
Lawn Sprinkler System (e), including backflow device on any one meter:
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 ot)erstaie of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
APPLICATION&_ (re 7c
DATE