2005, 05-04 Permit App: 05001428 Plumbing Reversal, ROWPLUMBING PERMIT APPLICATION
ne Phone: (509) 688-0036; FAX: (509) 688-0037
For Inspections, CaII (509) 688-0054
Project Address:
'zl
Community Development Department
Building Division
11707 E. Sprague Avenue, Suite 106
Spokane Valley, WA 99206
lM Attu „�,•z, (� Permit Use:
Owner j0 ng
Mailing Address: I. 1
Phone (Daytime Contact):
Contractor:/4Gc-,-, it a 5 Y 404-L.A,
Mailing Address: `�iSz.l 1/1 11.1y (((
City
License #:
State
Zip Code
Phone #:
State
Zip Code
BANKCARD NUMBER:
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
LAVS/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
=
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
NSTALLATION, ALTERATION, REPAIR,
REVERSALS
l
X
$6.00
=
f G
C_P C/
15
SEWAGE EJECTOR
GRINDER, 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:
0 CASH 0 CHECK
DATE:
SUBTOTAL
` _ 0
l(/ l/ �-7
0 VISA 0 MASTERCARD
PROCESSING FEE
$35.00
EXPIRES:
TOTAL PERMIT FEE DUE:
Li I OO
BANKCARD NUMBER:
AUTHORIZED SIGNATURE:
n
Sp"lane
4,00Valley
Call 24 hours before inspection required
Phone 509.688-0195 Fax 509.688-0037
DEPARTMENT OF PUBLIC WORKS
Anticipated start date Permit #
ROW CONSTRUCTION PERMIT
Location of property at fl Jo AR C-'� Vi i h Rd
(Address/Parcel #, if available)
Applicant Name % /i I Silel5.:�. Fax
Address / 1 / / Phone
Contractor's Name / or E Y i4 04 t‘ni
Address 30"2 r ii) lily R) Phone 2..5"-/ — gOs X'
Contractor's Reg.# l -G t '../.; ---g' .f 561 C D Expires 6" G %- O
PROJECT DESCRIPTION (Provide site sketch or plan as necessary for clarity)
1::' S wer Connection EI Driveway
El Curb & Gutter D Gas Installation/Repair
Cable/Conduit/Pole EJ Sidewalk Repair/Construction
El Water Installation/Repair El Other
Pavement Cut
Dimensions
Bond/insurance certification must be on file with the City. Bond #
Permittee Signature Approved
Date
I hereby authorize the City of Spokane Valley to charge the fee for this permit to my credit card.
Card # Expiration Date
Name of Holder
Signature
Fees Paid$
(Application) (Inspection)
In addition to the permit application fee of $16.00 (utility) or $25.00 (construction), inspection on
each permit will be billed to the permittee at a rate of $50.00 per hour with a $25.00 (1/2 hour)
minimum. Permittee signature constitutes an agreement to these terms and provisions.
Date 'nit
Work completed satisfactorily (Signed) Date
Permit not valid until One -Call Notification Ticket # entered here
PERMIT MUST BE KEPT ON SITE