1988, 04-10 Permit App: 00010613 Plumbing Fixtures•
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THESE PARTS OF THE FORM YOU UNDERSTAND
IProject I 10 b ,,
Firrst'' -, J l MI
Owner's Name Last ) Al/
itN KlSr-) 10,47 L90t a
Ro(ect Address (Street Name & Number)
/6'ato C 2foieu�yy
City
State Subdivisljn/Plat Name
Assessors Parcel p/ ?g/ / -) Lot
Block
Plat M
r/�
Applicant/`
Address
City
I State
Zip
Phone
Business Phone
Contractor
Gold Seal Mechanical Inc
Address
5524 E Boone
City
Spokane
I State
Wa
Zip
99212
Phone
509 535 5944
Contact
R Dixon _
Licensee
GO LD SM *290 C4
Business Phone
Describe Work
SFR
BarSink(s):
Drinking Fountain (s):
Floor Draln(s): 1
Washing Machine(s): /
Dsh Wahr(s):
Garb Dlap(s):
Kit SInk(s): I
Lndry Tray(s):
Sew Eject(s):
Urinal (s):
Wt Closet(s): 3
Lav(s): 3
Shower(s): .L
Tub(s): /
Bidet(s):
Other: Type;
Waste/Grease interceptor(s):
Sewer Y N Septic/Health No.:
Electric Water Heater(s): I
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 16:1-5:
(005 + :
/30 'i Sa
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 o i -r state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
APPLICATION
DATE