2005, 04-18 Permit App: 05001217 Sewer ReversalAit„
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PLUMBING PERMIT APP!IC:AT-BION
Phone: (509) 688-0036; FAX: (509) 688-0037
For Inspections, Call (509) 688-0054
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Project Address: ( Permit Use:
Owner: J' p433—e/0
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Community Development Department
Building Division
11707 E. Sprague Avenue, Suite 106
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Phone (D
State
cm vile_
State
Spokane Valley, WA 99206
05 -- 12
7
aytime Contact):
Mailing Address:
Contractor: Z -
Mailing Address:
-40
City
Licen
City
0
a_ eye917
Zip Code
Phone #:
Zip Code
METHOD OF PAYMENT:
❑ CASH
DATE:
0 CHECK
BANKCARD NUMBER:
❑ VISA
EXPIRES:
0 MASTERCARD
SUBTOTAL
PROCESSING FEE
TOTAL PERMIT FEE DUE:
$35.00
1i/
AUTHORIZED SIGNATURE:
DESCRIPTION OF WORK
# OF UNITS
X
COST
=
TOTAL AMOUNT
1
TOILETS
WATER CLOSET, BIDETS
X
$6.00
=
2
URINALS
X
$6.00
=
3
TUBS
X
$6.00
=
4
SHOWERS (PER TRAP)
BATH, STALL, ON-SITE BUILT
X
$6.00
=
5
SINKS
LAYS/BASINS, BAR, FLOOR, KITCHEN,
LAUNDRY, UTILITY, JANITOR, PHOTO,
X-RAY, FOOD, PREP/CULINARY MEAT
X
$6.00
=
6
DISHWASHER
X
$6.00
=
7
CLOTHES WASHER
X
$6.00
=
i 8
GARBAGE DISPOSAL
X
$6.00
=
9
WATER SOFTENER
X
$6.00
=
10
ELECTRIC HOT WATER TANK
NOTE: IF GAS, SEE MECHANICAL
X
$6.00
=
11
FLOOR DRAINS
AREA, CASE, COIL, TRENCH, CONDENSATE
X
$6.00
=
12
ROOF DRAINS/OVERFLOW
DRAINS
X
$6.00
13
FOUNTAINS, DRINKING
X
$6.00
=
14
WATER PIPING/DRAIN-IN WASTE,
VENT, PLUMBING, REVERSAL
NSTALLATIO N, REPAIR,
REVERSA
X
$6.00
=
15
SEWAGE EJECTOR
GRI ER, SUMP PUMP
X
$6.00
=
16
WATER USING DEVICE
ICE AN/OR COFFEE MAKER, HOSE BIB,
STEAMER
PROOFER, CARBONATOR, SWAMP COOLER
X
$6.00
=
17
CROSS CONNECTION DEVICE
VACUUM BREAKER, CHECK VALVE,
AND R.P.B.P.D. FOR: VATS, TANKS, BOILERS
X
$6.00
=
18
INTERCEPTORS
GREASE TRAP, SAND TRAP,
CHEMICAL HOLDING TANK
X
$6.00
=
19
MEDICAL GAS (per outlet)
NITROUS, OXYGEN
X
$6.00
=
20
MISCELLANEOUS PLUMBING
FIXTURE
X
$6.00
=
21
PRIVATE SEWAGE DISPOSAUSYS
X
$20.00
=
22
INDUSTRIAL WASTE
INTERCEPTOR
X
$15.00
=
METHOD OF PAYMENT:
❑ CASH
DATE:
0 CHECK
BANKCARD NUMBER:
❑ VISA
EXPIRES:
0 MASTERCARD
SUBTOTAL
PROCESSING FEE
TOTAL PERMIT FEE DUE:
$35.00
1i/
AUTHORIZED SIGNATURE: