2000, 03-07 Permit App: 00001371 Sewer, Plumbing ReversalSpokane Councy Division of Utilities
SEWER CONNECTIQN PERMIT APPLICATION FORM
PLEASE NOTE: This application form must be filled out accurately and in its entirety, and signed, or a permit will not be issued. Also note
that sewer permits are valid for 12 months form the date of issuance. No extensions will be granted.
Job address:.
rcv. t hnJ u�
City:
Zip:
PROJECT INFORMATION }may
Owner's FilAye,v
v
Dryin-S'wcr?
(Y/A) 1
Parcel Number (if known): 1..e9tg/Yt-P
City/State:
Zip:
Phone:
gid - 3//e44
First-time contractors or home -owners performing the installation mustJirst contact the Utilities Division in person or via phone [456-3604]) before a
permit can be issued
Name of Utilities Division person contacted:
CONTRACTOR INFORMATION
Contractor (company name):
Qt t-.rc h n t n r_ !✓ X.LtfcU-fnn
cL60 Ja11Q_yt Jai
Business address:• ,1
City/State: Zip: q zo
Sate coniractor license beCOULI eri
Contact: ,
am \
�11 n—r•-trtclit,e,
Phone Number: qtki -514 8 9
INTERIOR PLUMBING ALTERATIONS? (yes/no) circle one
Fill out the information in the table below if applicable"
Cont actor (if different from above);
f- x[n Plurnb.tn(�
Business Addre s:
J &-f I e :4-11/-.`
Phone:
61 2-2 -1S4-1
City/State/Zip
G-ICccnat_rGs1 WA
• ."For plumbing reversal fee inforination, see reverse side of this form.
FEE IN ORMATION
Sewer Connection: Number. of Buildings X (times) 5100 (per bldg) _ $ !1
T TA FEE
E
• For a single-family residential unit, one permit is required; •
• For a condominium, townhouse, duplex, triplex or fourplex with separate ownership (as determined by lot lines) separate address and separate stub, one
permit is required per address per stub;
• For a single building duplex, triplex or fourplex with single ownership, one permit is required
• Multiple buildings (apartments, industrial complexes) wit •le ownership, one permit required per building connecting to the sewer.
(For situations overed here, call theCounty Division of/Utilities @ 456-3604) y
APPLICANT SIGNATURE: ��i .-) Yates"/2DATE: ern
�'�
9 90.1�
Method of Payment:
0 Cash 0 Check 0 Visa 0 MasterCard 0 Discover Card
Date:
Bankcard Nu^Ser:
Authorized Signature:
Expires:
Spokane County Division of Building & Planning
1026 \Vest Broadway Avenue * Spokane WA 99260
Tel. No. (509) 456-3675 "- Fax No. (509) 456-4703 " TDD No. (509) 324-3166
PLUMBING PERMIT APPLICATION
PROJECT
ADDRESS:
PERMIT
USE:
OWNER:
PHONE: DAITUIE CONTACT
MAILING ADDRESS:
(street)
(city/state) (zip) .
CONTRACTOR: 15p rvita\/ P(A uniovi it
LICENSE: 8E6 yip;1r-- 0 � 2 -
M
0
PHONE: y, 2. 2. - I 57-1-1
MAILING ADDRESS. C, f g L- f to Ai 4 C7
re-ef) acres v/,A- 9 Q0-1 G
(street)
(city/state) (zip)
PLUMBING FIXTURES
DESCRIPTION
DETAIL
# OF
UNITS
man.
etmnar
COST
/UNIT
_ EQUALS
AMOUNT
B02:: TOILETS
WATER CLOSETS, BIDETS
X
S6
$
B03:: URINALS
-
x
56
=
$
804:: TUBS
BATH, JACUZZI, SPA, GARDEN
X
$6
=
$
BOA:: SHOWERS (per trap)
BASE, STALL ON-SITE BUILD
x
56
=
$
80.6:: SINKS
....
LAVS/BASINS, BAR, FLOOR, KITCHEN,
LAUNDRY, UTILITY, JANITOR, PHOTO,
X-RAY, FOOD (PREP/CULINARY/MEAL)
x
$6
=
$
B07: DISHWASHER
-
x
S6
=
5
BOB:: CLOTHES WASHER
-
x
S6
=
S
B09:: GARBAGE DISPOSAL/GRINDER
-
x
S6
=
S
B 10:: WATER SOFTENER
x
56
=
$
BH:: ELECTRIC HOT WATER TANKS .
(NOTE: if gas water tank, see mechanical)
x
56
=
S
B12:: FLOOR DRAINS
AREA, CASE, COIL TRENCH, CONDENSATE
X
56
=
S
813: ROOF DRAINS/OVERFLOW DRAINS (ea.;
-
x
$6
=
$
B14:: FOUNTAINS, DRINKING
- .
x
$6
=
$
B1 • - Di' 1 1 DR - 1-`•-ASTE-VENT/
dPLUMBING ' DU % •
INSTALLATION, ALTERATION, REPAIR,
REVERSALS
/
x
56
=
$
cf,
it
GRINDER, SUMP PUMP
x
$6
=
$
B17: WATER USING DEVICES
..._.
ICE AND/OR COFFEE,MAKER,
HOSE BIB, STEAMER, PROOFER,
CARBONATOR, SWAMP COOLERS
x
$6
=
$
B1$:: CROSS -CONNECTION DEVICES
.....
VACUUM BREAKER, CHECK VALVE,
AND R.P.B.P.D. FOR: VATS, SUMPS,
AND
TANKS, BOILERS, St SPRINKLER SYSTEMS
x
56
=-
B19:: INTERCEPTORS
GREASE TRAP, SAND TRAP,
CHEMICAL HOLDING TANK
x
56
=
$
B20:: MEDICAL GAS (per outlet/bottle station)
NITROUS, OXYGEN
X
$6
=
$
B21: MISCELLANEOUS FIXTURES
x
$6
=
$
Method of Payment:
Subtotal
PLUS: PROCESSING FEE
525.0C
❑ Cash Check❑ ❑
®
V
r ISA
❑+%%'
f
❑
1oismvenl
TOTAL PERMIT FEE DUE
5
FAXED PERMITS WILL ONLYBEACCEPTED WIlHPAYMENT OfA MAJOR CREDIT CARD
Date Expires:
MINIMUM PERMIT FEE IS 535.00
PLEASE MAKE CHECKS PAYABLE TO
SPOKANE COUY P
NTERMIT CENTER
Bankcard Number:
Authorized Signature:
12/19/97 masieAplumbpcnn.h,
Spokane County Division of Building Planning
1026 West Broadway Avenue * Spokane WA 99260
Tel. No. (509) 456-3675 49 N;. (509) 324-3198 * TDD No. (509) 324-3166