1985, 09-26 Permit App: 00007787 Plumbing Fixturesw
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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)
Ci(�l/L
ea
Department Use Only 7 7
Project No. / r L /
2 Project Address (Not Mailing Add s) CO Space Zip
C,c2 & , CL C:1.1,0 gr., tf-
3 City/Community
I State
Subdivision/Plat Name
4 Assessor Parcel No.
164Q.6)
Lot
1
Block
16 Contractor Firm Name
GOLD SEAL MECHANICAL, INC.
Street Address
13203 E FORREST
17 ZipCity
99216
I SPOKANE
State
WA
Phone
(509 ) 924 3423
18 Contact Person
R. DIXON
1 License No.
GO LD SM 290C4
Phone if different than above
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
State
Phone
( )
15 Describe Work: New Addition /Alteration f Replace/Repair n
p
Total Number
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): /
Lndry Tray(s):
I Sew Eject(s):
11 Urinal(s):
�?
WtrCloset (s): 3
Lav(s):
I Shower(s):
/
Tub(s): /
/
Bidet(s):
Other: Type;
12 Waste/Greaselnterceptor(s):
13 Sewer Y N Septic/Health No.:
14 Electric Water Heater(s): /
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:
(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 other state of local laws regulating construction or the performance of
Lconstruction.
SIGNATURE OF
VNER OR AGENT
APPLICATION ,0/G
DATE (�