2005, 04-13 Permit App: 05001157 ROW, Plumbing Fixtures,A,
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Project Address:
Owner.
PLUMBING PERMIT APPLICATION
Phone: (509) 688-0036; FAX: (5.09) 688-0037
For Inspections, Cali (509) 688-0054
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Mailing Address:
Contractor: €tj
Mailing Address: -3 0-2 I -iJ 1. 1
1- ` t I l
Community 136vel6pment Department
Building Division
11707 E. Sprague Avenue, Suite 106
Spokane Vali y, WA 99206
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Permit Use:
Phone (Daytime Contact):
>/Jr9�Lr/iVI Le 1 GI 12. 06
State Zip Code
Phone #:
Lj9-zI-2
City
License #:
8Y
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
1
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
I
X
$6.00
=
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:
❑ CASH 0 CHECK
DATE
SUBTOTAL
0 VISA 0 MASTERCARD
PROCESSING FEE
$35.00
EXPIRES:
TOTAL PERMIT FEE DUE:
BANKCARD NUMBER:
AUTHORIZED SIGNATURE:
Splikane
eY
Call 24 hours before inspection required
Phone 509.688-0195 Fax 509.688-0037
DEPARTMENT OF PUBLIC WORKS
Anticipated start date -/ - (2 -(95— Permit #
ROW CONSTRUCTION PERMIT
Location of property -.3t7`2_. / /p Ab
(Address/Parcel #, if available)
Applicant Name 4,J4 196?"-- Fax
Address ) ( 1 ( Phone
Contractor's Name ISL 1,11 E CYe f, /At,
Address
i92_/ IL)
Phone 2-S7 ofE)
Contractor's Reg.# Expires
PRO T DESCRIPTION (Provide site sketchor plan as necessary for clarity)
Sewer Connection n Driveway
0 Curb & Gutter ❑ Gas Installation/Repair
❑ Cable/Conduit/Pole
❑ Water Installation/Repair
❑ Pavement Cut
❑ Sidewalk Repair/Construction
❑ Other
Dimensions
Bond/insurance certification must be on file with the City. Bond #
Permittee Signature Approved
Date
I hereby authorize the City of Spokane Valley to charge the fee for this permit to my credit card.
Card # Expiration Date
Name of Holder
Signature
Fees Paid$
(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.
Work completed satisfactorily (Signed) Date
Date
!nit
Permit not valid until One -Call Notification Ticket # entered here
PERMIT MUST BE KEPT ON SITE