1985, 05-06 Permit App: 00005309 Plumbing FixturesU)
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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)
Masco Builders
(M)
Department Use Only
Project No.
2 Project Address (Not Mailing Address)
11916 E 24th
Space Zip
3 City/Community
State
Subdivision/ Plat Name
4 Assessor Parcel No.
Lot
Block
16 Contractor Firm Name
GOLD SEAL MECHANICAL, INC.
Street Address
13203 E FORREST
17 Zip
99216
City
SPOKANE
State
WA
Phone
(509 ) 924 3423
18 Contact Person
R. DIXON
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 EX; Addition/Alteration ❑
Replace/Repair F.
Total Number
of Fixtures: /v
10 Applicant Name
Street Address
11 ZipCity
State
Phone
( )
9 Bar Sink (s):
Drinking Fountain(s):
Floor Drain (s):
1
Washing Machine(s):
10 Dsh Wshr(s):
Garb Disp(s):
Kit Sink(s):
f
s
Lndry Tray(s):
Sew Eject (s):
11 Urinal(s):
WtrCloset(s):
Lav (s)
Shower (s):
I
Tub(s): /
t
Bidet(s):
Other: Type;
12 Waste/Grease Interceptor(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 pirformance of
construction.
SIGNATURE OF APPLICATION
OWNER OR AGENT OL DATE ��