1985, 03-11 Permit App: 00004412 Plumbing Fixtures R
PLUMBING PERMIT APPLICATION WORKSHEET (--,•2 '
` PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name Last) (First) (M) Department Use Only ,„/"
i9/L S ` Cay/�t�� [Project No. Imo' -
2 Project Address(Not Mailing Address) Space Zip 111
..'."6' 13 /v-14-C
3 City/Community I State Subdivision/Plat Name
4 Assessor Parcel No. I Lot Block
16 Contractor Firm Name Street Address
Gold Seal Mechanica Inc 13203 F Forrest
17 Zip City State Phone
99216 Spokane WA ( 509 ) c)24 142'
18 Contact Person License No. Phone if different than above
R Dixon GO LD SM 290 C4
8 Owner/Agent(if different than#1 above) ' Business Address
9 Zip City State Phone
( )
15 Describe Work: New X ; Addition/Alteration El ; Replace/Repair I: Total Number
of Fixtures: /3
10 Applicant Name Street Address
11 Zip City State Phone
( )
* _. J;
9 BarSink(s): Drinking Fountain(s): Floor Drain(s): ! Washing Machine(s): 1
10 Dsh Wshr(s): Garb Disp(s): Kit Sink(s): 1 Lndry Tray(s): Sew Eject(s):
11 Urinal(s): Wtr Closet(s): 3 Lav(s): 3 Shower(s): 2.____Tub(s):( Bidet(s):
co Other: Type;
W
Cr
D
X12 Waste/Grease Interceptor(s):
L
LL
O 13 Sewer V N Septic/Health No.:
Cr
W
CO 14 Electric Water Heater(s):
/
Drains-Roof:
2
o
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+:
4,/
CPL--
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
construction.
SIGNATURE OF6C2---rAPPLICATION
OWNER OR AGENT DATE ,3--- /1-- (5'.-