1985, 03-17 Permit App: 00004501 Plumbing Fixtures d e 1
c '' PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) (M) I Department Use Only
AI tot,4(-11,-/4 Project No.
2 Project Address(Not Mailing Address) r Space Zip
1017 •1.
3 City/Community Subdivision/Plat Name
4 Assessor Parcel No. Lot Block /,:f .-3/
"
16 Contractor Firm Name Street Address
Gold Seal Mechanical, Inc. 13203 E. Forrest
• 17 ZipCity State Phone
99216 ( Spokane Wa 509 ) 924 3423
18 Contact Person I License No. Phone if different than above
R. Dixon GO LD SM 290C4
8 Owner/Agent(if different than#1 above) Business Address
▪ 9 Zip City State Phone
( )
15 Describe Work: New ❑ ; Addition/Alteration El ; Replace/Repair E Total Number /O
of Fixtures:
10 Applicant Name Street Address
11 Zip City State Phone
( )
*
9 Bar Sink(s): Drinking Fountain(s): Floor Drain(s): / Washing Machine(s):
10 Dsh Wshr(s): Garb Disp(s): Kit Sink(s): I Lndry Tray(s): Sew Eject(s):
11 Urinal(s): Wtr Closet(s): 2 Lav(s): Shower(s): / I Tub(s): , Bidet(s):
Other: Type;
W
D
X12 Waste/Grease Interceptor(s):
LL
LL
O 13 Sewer Y N Septic/Health No.:
M
W
03 14 Electric Water Heater(s): 1 Drains-Roof:
m
Z 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: (Or)5+:
t!C,® el (lO
5-Z
-
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
c---:__ _____construction.
SIGNATURE OF APPLICATION
OWNER OR AGENT DATE 3— i I; es-