1986, 06-04 Permit App: 00012367 Plumbing Fixtures •
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name ,/ (Last) (First) (M) Department Use Only
W U� �`(!ply A /L/ co [Z Project No.
2 Project Address(Not Mailing Address) Space Zip
/13 ° ( 0 ya �.j C '
3 City/CompuAy I State Subdivision/Plat Name
ccrC)k c/J� �.
4 Assessor Parcel No. I Lot Block
16 Contractor Firm Name Street Address
RIVER CITY PLUMBING INC. N 111 Vista Bldg. 7, D
17 LpCity State Phone
99212 , Spokane "Ja. ( ) 921 -8028
18 Contact Person 1 License No. Phone If different than above
Audrey Hobeck RIVERCP190KA
8 Owner/Agent(if different than 411 above) Business Address
9 Zip City I State Phone
15 Describe Work: New 0 ; Addition/Alteration 0 ; Replace/Repair 0 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 Dah Wshr(s): Garb Disp(s): Kit Sink(s): Lndry Tray(s): Sew Eject(s):
11 Urinal(s): WtrCloset(s): 3 Lav(s): `� I Shower(s): I Tub(s): ) Bidet(s):
W
Other: Type; J /
Q
X12 Waste/Grease Interceptor(s):
U-
tL 13 Sewer Y N Septic/Health No.:
0
tL
!1J
CO 14 Electric Water Heater(s): Drains-Roof:
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+:
C3
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 OF ,�r / APPLICATION
OWNER OR AGENT /i DATE '' ` 417L.