1992, 08-05 Permit App: 92006072 Lawn Sprinkler SystemPLUMBING PERMIT APPLICATION FORM
Information Worksheet
JOB STREET ADDRESS: / 2 l! 5. /VI. /4 a L b
CITY/STATE/ZIP: VA --A DAL-C/A/A/c) 903 ? PARCEL NUMBER:
OWNER: 'R lc NI 12-1.. , M A 147*1 rJ PHONE NUMBER: 9 Z 8 Zo 7 $
MAILING ADDRESS: l 2. 11 . f14 Alt t c o c. i) �/& )4 DA c-�^ w 4 9 90 3 7
(Street) (City/State) (Zip)
CONTRACTOR: LICENSE NUMBER:
PHONE NUMBER:
MAILING ADDRESS:
qz: tool
kvoS� R.l l�►K ( (Street)_ (City/State)
(Zip)
PLUMBING WORKSHEET/FEE SCHEDULE
DESCRIPTION
TOILETS
SHOWERS
KITCHEN SINKS
DI SHvAS HERS ><>
GARBAGE DISPOSAL
tTHS> IVHH<€`<
UTILITY SINKS
EL TR( TATE t E
FLOOR DRAINS
BAR SINKS
LAWN SPRINKLER - FOR EACH BACKFLOW DEVICE
WATER SOFTENER
DRINKING FOUNTAIN
NOTE: MINIMUM PERMIT FEE IS $35.00
SIGNATURE
NUMBER
OF UNITS
X EACH
UNIT
= AMOUNT
x 6.00 =
x6.00 =
x 6.00 =
x 6.00 =
x 6.00 =
x6.00 =
x 6.00 =
x 6.00 =
x 6.00 =
x6.00 =
x 6.00 =
x6.00 =
x 6.00 =
x6.00 =
x 6.00 =
x 6.00 =
x 6.00 =
x 6.00 =
x6.00 =
Co
SUBTOTAL
$
PLUS: PROCESSING FEE
+ $ 25.00
EQUALS: TOTAL PERMIT
FEE DUE
= $ -5.e7i
Spokane County Division of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509) 456-3675