1986, 06-04 Permit App: 00011437 Plumbing Fixtures t
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
IProject# // /
Owner's Name Last First MI
Project Address(Street Name&Number) / Y9/7 //_�/
di
City State T Subdivision/Plat Name
Assessors Parcel# Lot Block Plat#
Applicant Address
City I State Zip Phone
Business Phone
Contractor
Address
Gold Seal Marhaniral Tnr 5524 E Boone
City State Zip Phone
Spokane WA 99212 509 535 5944
Contact License# Business Phone
R Dixon GO LD SM *290 C4
Describe Work
SFR
Bar Sink(s): Drinking Fountain(s): Floor Drain(s): ! Washing Machine(s): /
Dsh Wshr(s): Garb Disp(s): Kit Sink(s): Lndry Tray(s): Sew Eject(s):
Urinal(s): Wtr Closet(s): y Lay(s): Shower(s): / Tub(s): , Bidet(s):
w
rn Other: Type;
CC
I- Waste/Grease Interceptor(s):
U-
LL Sewer Y N Septic/Health No.:
O
m Electric Water Heater(s): Drains-Roof:
2
Z 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+:
/aY 4(�
s
I certify that the above information as submitted by me is true and correct and further, agree t at 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 an oth- - - • local laws regulating construction or the performance of
construction.
SIGNATURE OF / APPLICATION L , __((�
OWNER OR AGENT - DATE