1992, 02-26 Permit App: 92001095 Plumbing FixturesPLUMBINCkPERMIT APPLICATION FORM
Information Wofksheet
JOB STREET ADDRESS: S 9i 7 / 4,, e ✓
CITY/STATE/ZIP: PARCEL NUMBER:
OWNER: PHONE NUMBER:
MAILING ADDRESS:
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(Str t) (City/State) (Zip)
CONTRACTOR: A % co -/2 LICENSE NUMBER: /7aXJ Cor /Ei//
/
//)) PHONE NUMBER: 9d/-; ' -99"
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MAILING ADDRESS: //`"/ / 4' a/4 .v^—t �ncv/C�-Yic, 99, 0A
(Street) d t (City/State) (Zip)
PLUMBING WORKSHEET/FEE SCHEDULE
DESCRIPTION
TOILETS
SINKS
SHOWERS
BATHTUBS
KITCHEN SINKS
DISH WASHERS
GARBAGE DISPOSAL
CLOTHES WASHER'?
UTILITY SINKS
ELECTRIC WATER HEATERS
FLOOR DRAINS
FLOORSINKS
BAR SINKS
ROOF DRAINS
LAWN SPRINKLER - FOR EACH BACKFLOW DEVICE
SEWAGE EJECTOR
WATER SOFTENER
URINAL
DRINKING FOUNTAIN
NOTE: MINIMUM PERMIT FEE IS $35.00
SIGNATURE . ° �li�=i/
NUMBER
OF UNITS
X EACH
UNIT
= AMOUNT
x 6.00 =
x6.00 =
x 6.00 =
x 6.00 =
x 6.00 =
x 6.00 =
x 6.00 =
x 6.00 =
x 6.00 =
x 6.00 =
x 6.00 =
x6.00 =
x 6.00 =
x 6.00 =
x 6.00 =
x 6.00 =
x 6.00 =
x 6.00 =
x 6.00 =
/
SUBTOTAL
$
PLUS: PROCESSING FEE
+ $ 25.00
EQUALS: TOTAL PERMIT
FEE DUE
= $
Spokane County Division of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509) 456-3675