1984, 09-19 Permit App: 00002455 Plumbing Fixtures*
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) (M)
Department Use Only
(ice
5
Tupper Inc .
Project No. 14r
2 Project Address (Not Mailing Address) Space Zip
E. 14707 Olympic
3 City/Community
State
Subdivision lPlat Name
4 Assessor Parcel No. I
Lot
Block
16 Contractor Firm Name
John Burke Plmb. & Htg.
Street Address
P. 0. Box 2691
17 Zip
99220
City
Spokane
State
Wa,
Phone
635-0066
18 Contact Person
John
License No.
JQHNBPH162JJ
Phone if different than above
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
State
Phone
( )
15 Describe Work: New a; Addition/Alteration CI; Replace/Repair CI
12 Number 12
of Fixtures:
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
9 Bar Sink(s):
Drinking Fountain(s):
Floor Drain (s): 1
Washing Machine(s): 1
10 Dsh Wshr(s):
Garb Disp(s):
Kit Sink(s): 1
Lndry Tray(s):
Sew Eject(s):
11 Urinal(s):
WtrCloset(s): 3
Lav(s): 3
Shower(s): 1
I Tub(s): 1
Bidet(s):
Other: Type;
12 Waste/Grease Interceptor(s):
13 Sewer Y N Septic/Health No.:
14 Electric Water Heater(s): 1
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 lawsregulatingconstruction or the performance of
construction.
SIGNATURE OF
OWNER OFA -AGENT
Afam . . _/iii//
APPLICATION
9-19-84
DATE
00