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2007, 04-18 Permit App: 07001289 Residence_ Project Number: 07001289 Inv: 1 Application THIS IS NOT A PERMIT Penalties will be assessed for commencing work without a permit Date: 4/18/2007 Page 1 of 3 Project Information: Permit Use: SFR W/ATT GAR Setbacks: Front 38 Left: 5 Right: 5 Rear: 19 Site Information: Plat Key: Contact: DIAMOND ROCK CONSTRUCTION Address: 2602 N SULLIVAN C - S - Z: SPOKANE VALLEY, WA 99037 Phone: (509) 924-8964 Group Name: Project Name: Name: Range District: East Parcel Number: 5519L0602 Block: SiteAddress: 415 S MCKEE AVE Location:: CSV Lot: Owner: Name: CRAPO, DENNIS A & MELISSA A Address: 15321 E MISSION AVE VERADALE, WA 99037 - Zoning: UR -3.5 Urban Residential 3.5 Water District: 134 CONSOLIDATED ID #19 Area: 200,970 Sq Ft Width: 0 Nbr of Bldgs: 0 Nbr of Dwellings: 0 Review Information Hold: ❑ Depth: 0 Right Of Way (ft): 0 Review Building Plan Review Released By: Driveway/Approach Originally Released: 4/16/2007 By: TMELBOU Released By: Originally Released: 4/16/2007 By: jdavis Landuse/Zoning/HE Conditions Released Sewer Review • Originally Released: 4/17/2007 By: cjjanssen Released By: Permits: _ . ... ... Operator: JD Printed By: JD Print Date: 4/18/2007 Project Number: 07001289 Inv: 1 Application THIS IS NOT A PERMIT Penalties will be assessed for commencing work without a permit Date: 4/18/2007 Page 2 of 3 Approach Contractor: DIAMOND ROCK Firm: DIAMOND ROCK CONSTRUCTIO Address: 2602 N SULLIVAN SPOKANE VALLEY WA 99216 Item Description APPROACH -CONST IN ROW Phone: (509) 924-8964 Units Unit Desc 1 NUMBER OF Fee Amount $50.00 Permit Total Fees: $50.00 Building Permit Contractor: DIAII'IOND ROCK Firm: DIAMOND ROCK CONSTRUCTIO Address: 2602 N SULLIVAN Phone: (509) 924-8964 SPOKANE VALLEY WA 99216 This Application: Total Project: DescriptionGrp Type Notes Sq Ft Valuation Sq Ft Valuation I&2 FAMILY R-3 VB 1,570 $143,435.20 1,570 $143,435.20 BASEMENT U R-3 VB 1,570 $23,550.00 1,570 $23,550.00 COV DECK R-3 VB 40 $600.00 40 $600.00 DECK OPEN R-3 V13 60$900.00 60 $900.00 GARAGE U-1 VB 393 $7,467.00 393 $7,467.00 Item Description RESIDENTIAL PERMIT FEE WSBC SURCHARGE SF PLNS RVW < 7999 SQ FT Totals: 3,633 $175,952.20 3,633 $175,952.20 Units Unit Desc 1 SELECT 1 SELECT 1 SELECT Permit Total Fees: Mechanical Permit Fee Amount $1,419.35 $4.50 $567.74 $1,991.59 Contractor: DIAMOND ROCK Firm: DIAMOND ROCK CONSTRUCTIO Address: 2602 N SULLIVAN Phone: (509) 924-8964 SPOKANE VALLEY WA 99216 Item Description DUCT SYSTEMS GAS WATER HEATER GAS APPLIANCE<=100,000BTU GAS PIPING VENTILATING FANS CLOTHES DRYER FLOOD -TYPE II Units Unit Desc 1 NUMBER OF 1 NUMBER OF 1 NUMBER OF 2 # OF UNITS 3 NUMBER OF 1 NUMBER OF 1 NUMBER OF Operator: JD Printed By: JD Fee Amount $10.00 $10.00 $12.00 $2.00 $30.00 $10.00 $10.00 Permit Total Fees: $84.00 Print Date: 4/18/2007 Project Number: 07001289 Inv: 1 Application Date: 4/18/2007 Page 3 of 3 THIS IS NOT A PERMIT Penalties will be assessed for commencing work without a permit Plumbing Permit Contractor: DIAMOND ROCK Firm: DIAMOND ROCK CONSTRUCTIO Address: 2602 N SULLIVAN Phone: (509) 924-8964 SPOKANE VALLEY WA 99216 Item Description Units Unit Desc Fee Amount TOILETSBIDETS 2 NUMBER OF $12.00 SINKS 4 NUMBER OF $24.00 TUBS 2 NUMBER OF $12.00 DISH WASHERS 1 NUMBER OF $6.00 CLOTHES WASHER 1 NUMBER OF $6.00 MISCELLANEOUS FIXTURES 2 NUMBER OF $12.00 Permit Total Fees: $72.00 Notes: See plat file for TURTLE CREEK SOUTH 2ND for special drainage requirements Payment Summary: ._-- Permit Type Fee Amount Invoice Amount Amount Paid Amount Owing Approach $50.00 $50.00 $0.00 $50.00 Building Permit $1,991.59 $1,991.59 $0.00 $1,991.59 Mechanical Permit $84.00 $84.00 $0.00 $84.00 Plumbing permit $72.00 $72.00 $0.00 $72.00 $2,197.59 $2,197.59 $0.00 $2,197.59 Disclaimer: Submittal of this application certifies the owner (or person(s) authorized by the owner) has both examined and finds the information contained within to be true and correct, and agrees that all provisions of laws and/or regulations governing this type of work will be complied with. Subsequent issuance of a permit shall not be construed to be a permit for, or an approval of, any violation of any of the provisions of the code or of any other state or local laws or ordinances. Signature: Operator: JD Printed By: JD Print Date: 4/18/2007 Project Number: 07001289 Inv: 1 Application THIS IS NOT A PERMIT Penalties will be assessed for commencing work without a permit Date: 4/16/2007 Page 1 of 3 Project Information: Permit Use: SFR W/ATT GAR Setbacks: Front 38 Left: 5 Right: 5 Rear: 19 Site Information: Plat Key: Contact: DIAMOND ROCK CONSTRUCTION Address: 2602 N SULLIVAN C - S - Z: SPOKANE VALLEY, WA 99037 Phone: (509) 924-8964 Group Name: Project Name: Name: Range District: East Parcel Number: 55191.0602 Block: SiteAddress: 18506 E 4TH AVE Location:: CSV Lot: Owner: Name: CRAPO, DENNIS A & MELISSA A Address: 15321 E MISSION AVE VERADALE, WA 99037-. Zoning: UR -3.5 Urban Residential 3.5 Water District: 134 CONSOLIDATED ID #19 Area: 200,970 Sq Ft Width: 0 Nbr of Bldgs: 0 Nbr of Dwellings: 0 Review Information: Hold: 0 Depth: 0 Right Of Way (ft): 0 Review Building Plan Review Released By: Driveway/Approach Originally Released: 4/16/2007 By: TMELBOU Released By: - Originally Released: 4/16/2007 By: jdavis Landuse/Zoning/IIE Conditions _ReleasedBYQb:/._ :,:uc;J Sewer Review :Released By: vr, Permits: Operator: JD Printed By: JD Print Date: 4/16/2007 Project Number: 07001289 Inv: 1 Application THIS IS NOT A PERMIT Penalties will be assessed for commencing work without a permit Date: 4/16/2007 Page 1 of 3 Project Information: Permit Use: SFR W/ATT GAR Setbacks: Front 38 Left: 5 Right: 5 Rear: 19 Site Information: Contact: DIAMOND ROCK CONSTRUCTION Address: 2602 N SULLIVAN C - S - Z: SPOKANE VALLEY, WA 99037 Phone: (509) 924-8964 Group Name: Project Name: Plat Key: Name: Range District: East Parcel Number: 55191.0602 Block: SiteAddress: 18506 E 4TH AVE Location:: CSV Lot: Owner: Name: CRAPO, DENNIS A & MELISSA A Address: 15321 E MISSION AVE VERADALE, WA 99037 - Zoning: UR -3.5 Urban Residential 3.5 Water District: 134 CONSOLIDATED ID #19 Hold: ❑ Area: 200,970 Sq Ft Width: 0 Depth: 0 Right Of Way (ft): 0 Nbr of Bldgs: 0 Nbr of Dwellings: 0 Review Information: Review Building Plan Review Released By: - - Driveway/Approach Originally Released: 4/16/2007 By: TMELBOU Released By: - Originally Released: 4/16/2007 By: jdavis Landuse/Zoning/HE Conditions Released By': • Sewer Review Permits • Released Bye Operator: JD Printed By: JD . Pnnt Date: 4/16/2007 Project Number: 07001289 Inv: 1 Application THIS IS NOT A PERMIT Penalties will be assessed for commencing work without a permit Date: 4/16/2007 Page 2 of 3 Approach Contractor: DIAMOND ROCK Firm: DIAMOND ROCK CONSTRUCTIO Address: 2602 N SULLIVAN SPOKANE VALLEY WA 99216 Item Description APPROACH -CONST IN ROW Phone: (509) 924-8964 Units Unit Desc 1 NUMBER OF Permit Total Fees: Building Permit Fee Amount $50.00 $50.00 Contractor: DIAMOND ROCK Firm: DIAMOND ROCK CONSTRUCTIO Address: 2602 N SULLIVAN Phone: (509) 924-8964 SPOKANE VALLEY WA 99216 This Application: Total Project: Description Grp Type Notes Sq Ft Valuation Se Ft Valuation 1&2 FAMILY R-3 VB 1,570 $143,435.20 1,570 $143,435.20 BASEMENT U R-3 VB 1,570 $23,550.00 1,570 $23,550.00 COV DECK R-3 VB 40 $600.00 40 $600.00 DECK OPEN R-3 VB 60 $900.00 60 $900.00 GARAGE U-1 VB 393 $7,467.00 393 $7,467.00 Item Description RESIDENTIAL PERMIT FEE WSBC SURCHARGE SF PLNS RVW < 7999 SQ FT Totals: 3,633 $175,952.20 3,633 5175,952.20 Units Unit Desc Fee Amount . . 1 SELECT $1,419.35 1 SELECT $4.50 1 SELECT 5567.74 Permit Total Fees: Mechanical Permit $1,991.59 Contractor: DIAMOND ROCK Firm: DIAMOND ROCK CONSTRUCTIO Address: 2602 N SULLIVAN Phone: (509) 924-8964 SPOKANE VALLEY WA 99216 Item Description DUCT SYSTEMS GAS WATER HEATER GAS APPLIANCE<=100,000BTU GAS PIPING VENTILATING FANS CLOTHES DRYER HOOD -TYPE II Units Unit Desc 1 NUMBER OF 1 NUMBER OF 1 NUMBER OF 2 # OF UNITS 3 NUMBER OF 1 NUMBER OF 1 NUMBER OF Fee Amount $10.00 $10.00 $12.00 $2.00 $30.00 $10.00 $10.00 Permit Total Fees: $84.00 Operator: JD Printed By: JD Print Date: 4/16/2007 Pro i ect Number: 07001289 Inv: 1 Application THIS IS NOT A PERMIT Penalties will be assessed for commencing work without a permit Date: 4/16/2007 Page 3 of 3 Plumbing Permit Contractor: DIAMOND ROCK Firm: DIAMOND ROCK CONSTRUCTIO Address: 2602 N SULLIVAN Phone: (509) 924-8964 SPOKANE VALLEY WA 99216 Item Description Units Unit Desc Fee Amount TOILETSBIDETS 2 NUMBER OF $12.00 SINKS 4 NUMBER OF $24.00 TUBS 2 NUMBER OF $12.00 DISH WASHERS 1 NUMBER OF $6.00 CLOTHES WASHER 1 NUMBER OF $6.00 MISCELLANEOUS FIXTURES 2 NUMBER OF $12.00 Notes Permit Total Fees: $72.00 See plat file for TURTLE CREEK SOUTH 2ND for special drainage requirements Payment Summary* Permit Type Fee Amount Invoice Amount. Amount Paid Amount Owing Approach $50.00 $50.00 $0.00 $50.00 Building Permit $1,991.59 $1,991.59, $0.00 $1,991.59 Mechanical Permit $84.00 $84.00 $0.00 $84.00 Plumbing Permit $72.00 $72.00 $0.00 $72.00 $2,197.59 $2,197.59 $0.00 $2,197.59 Disclaimer: Submittal of this application certifies the owner (or person(s) authorized by the owner) has both examined and finds the information contained within to be true and correct, and agrees that all provisions of laws and/or regulations governing this type of work will be complied with. Subsequent issuance of a permit shall not be construed to be a permit for, or an approval of, any violation of any of the provisions of the code or of any other state or local laws or ordinances. Signature: Operator: JD Printed By: JD Print Date: 4/16/2007 S ®lane ..00110 Valley Community Development Permit Center 11707 E Sprague Ave, Suite 10 Spokane Valley, WA 9920 (509)688-0036 FAX: (5091168 WWW spokanevalle •.org.con Residential Construction Permit Application EC f\f n ILCt1 ERMI�T-: »r.:; ✓.,.,.,...,. NUMBEI MAR •-• 207 0037 \4,/ INTERMIT FEE4 UOU'LOuu tat New Construction o Addition/Remodel o Other: o Accessory Bldg o Deck SITE ADDRESS LA 15 5, A C it ASSESSORS PARCEL NO: LEGAL DESCRIPTION: Lot q i?) /< l , dingo`wner,•a' .,pp ' '' Name: 0 i cuno ✓t td 'ac ; K (Oyl s t Address: Phone: gay -796q Fax: 926..'-709 f / O Lic No: Exp. Date: City: City Business Lic No: Zip: # OF BEDROOMS: 3 DISCI AIMFP Phone: HEAT SOURCE: Nai-vrc,l 6c.S i,.rnac4 Fax: ContactsPerson Name: Pau Phone: 2 t 1-1-19 Zy Describe the scope of work in detail: 3v;Id .a Ale1U SF1. li@ontractorSI��x ;�.�- ..,._ .��.,_. :�c��,. a Name: Dia ✓norl(l 12it it ............... TOTAL HABITABLE SPACE: — &S-7° Address: 2,6OZ Al, Svi/(vain FGi. 2Nu FLOOR SQ. FTG: -- City: Spokn.1e V Y Zip: 9 e Zl 6 IMPERVIOUS SURFACE AREA: A//R Phone: gay -796q Fax: 926..'-709 f / O Lic No: Exp. Date: GARAGE SQ. FTG: 92- 3 93 City Business Lic No: 30% SLOPES ON PROPERTY: /VI✓i- Cost of Project: $ 70, vo 0 **************The following MUST be complete•(write N/A if not a 1' bl * pp cea e) HEIGHT TO PEAK: 'ZSLIU DIMENSIONS:# NC/S'Z' OF STORIES: 1 ............... TOTAL HABITABLE SPACE: — &S-7° MAIN FLOOR TO SQ. FTG: 13.317 /5 70 2Nu FLOOR SQ. FTG: -- UNFIN BASEMENT SQ. FTG: IMPERVIOUS SURFACE AREA: A//R / O FINISHED BASEMENT SQ. FTG: r GARAGE SQ. FTG: 92- 3 93 DECIteSTAD SQ. FTG: G. 4.. itegatEr 30% SLOPES ON PROPERTY: /VI✓i- # OF BEDROOMS: 3 DISCI AIMFP CONSTRUCTION TYPE: SP( HEAT SOURCE: Nai-vrc,l 6c.S i,.rnac4 SEWER OR SEPTIC? Seder The permitee verifies, acknowledges and agrees by their signature that: 1) If this permit is for construction of or on a dwelling, the dwelling is/will be served by potable water. 2) Ownership of this City of Spokane Valley Permit inure to the property owner. 3) The signatory is the property owner or has permission to represent the property owner in this transaction. 4) All construction is to be done in full compliance with the City of Spokane Valley Development Code. Referenced codes are available for review at the City of Spokane Valley Permit Center. 5) This City of Spokane Valley Permit is not a permit or approval for any violation of federal, state or local laws, codes or ordinances. 6) Plans or additional information may be required to be submitted, and subsequently approved before this application can be processed. Signature Date Method of Payment: (Faxed permit applications will only be accepted with majorbankcard) ❑ Cash ❑ Check 9 Mastercard 9 VISA Bankcard #: Expires: VIN#: Authorized Signature: REVISED 8/25/2005 3)7 / 1o7 ❑ Other Permit Center SiliOkane 11707 E Sprague Ave, Suite 106 Valley Spokane Valley, WA 99206 (509)688-0036 FAX: (509)688-0037 Community Development www.spokancvallev rn _acom Mechanical Permit Application o Commercial ,-Residential :;PERMi41UMi313R ::PERMIT PEE SITE ADDRESS -115 /u. 144c ,: -Building owner :t:`?4� K�;a' :i=;_{3.r s=_�- _.. T:-"-vijp: i3' -:v - --:y.:�._rA:S�*{-_='�`-k-=.r:=%.'- - _ 4 _ ... ._,-_,a....�cs :;"�6"s't=: `'+3l-_.-._K�:4=P��r_.w"A�<.�.a �c e5.�.:y �, :°'. --_ ,L Name. b'?TA e4)AL/ 2ccC i0✓ s..) Phone: ey_29-F'9L (O(/ Fax 92 E' S-0 GIC./. e0 2 N. SJii i ✓Gi ✓) Keit City S`PO Fjint v/t$tate t.-4 Zi /C, P 7 i z %.6 ,Address ?Con[rac ora=_t=�`=7r C 4�-7-L- 7t1 -w r_C: is 's-':, - 3 q,:'£`'}:= =-.rt r�;- �. Y " �� -�/. _-:AL-. � 4 wSF.-i_. F 3Y� 'may t-3.rY--ti`-"em='i"s=;�'�' .._ �.:bi .. :Y.i. ':.: '1 Y +�=Yi T.74' e /- Name' Co tvukr f C N 1--r-c, I Phone. Fax: Address' City State Zip License No: City Business License No- GContect -7: I.: • �'a . j•'4 ri .-sa'i .s:2.--^F�`k'"$'7 , i'r m -"'3n.';x li -=^ Name: c:::4 N i Phone. t/ $ - 9 Q z c( # OF UNITS X COST 1 FUEL BURNING APPLIANCE Equal to or less than 100,000 X $12 00 2 FUEL BURNING APPLIANCE More than 100,000 X $15.00 TOTAL AMOUNT = IZ 3 UNLISTED APPLIANCE (Additional Fee) Equal to or less than 400,000 X $50.00 4 UNLISTED APPLIANCE (Additional Fee) More than 400,000 X $100.00 5 USED APPLIANCE (WSEC min. AFUE rating) Equal to or less than 400,000 X $50.00 6 USED APPLIANCE (WSEC min. AFUE rating) More than 400,000 X $100 00 7 BOILER/REFRIGERATION 1 - 100M BTU X $12 00 8 BOILER/REFRIGERATION 101 - 500M BTU X $20.00 9 BOILER/REFRIGERATION 501 - 1,000M BTU X $25.00 10 BOILER/REFRIGERATION 1,001 - 1,750M BTU X $35.00 11 BOILER/REFRIGERATION More than 1,750M BTU X $60 00 12 GAS LOG, GAS INSERT, GAS FIREPLACE X $10.00 13 RANGE X $10.00 14 DRYER X $10 00 10 15 FUEL BURNING WATER HEATER X $10.00 • 10 16 MISC. FUEL BURNING APPLIANCE x $10 00 17 GAS PIPING (each outlet) X $1.00 2 18 DUCT SYSTEMS X $10.00 IJ 19 VENTILATING FANS 3 x $10 00 30 20 AIR HANDLER (DOES NOT include ducting) Equal to or less than 10,000 CFM X $12 00 21 AIR HANDLER (DOES NOT include ducting) Greater than 10,000 CFM X $15 00 22 EVAPORATIVE COOLERS X $10 00 23 TYPE I HOOD x $50.00 24 TYPE II HOOD X $10.00 10 25 HEAT PUMP/AIR CONDITIONER 0-3 TON X $12.00 26 AIR CONDITIONER 3-15 TON X $20 00 27 AIR CONDITIONER 15-30 TON X $25.00 28 AIR CONDITIONER 30-50 TON X $35.00 29 AIR CONDITIONER More than 50 TON X $60.00 30 LPG STORAGE TANK X $10.00 31 WOOD OR PELLET STOVE/INSERT X $10 00 32 WOOD STOVE - FREE STANDING X $25.00 33 REPAIR & ADDITIONS X $15.00 34 VENTILATION SYSTEMS X $12.00 35 VENTILATION MECHANICAL EXHAUST X $12.00 36 INCINERATOR - RESIDENCE X $19.00 37 INCINERATOR - COMMERCIAL X $22.00 METHOD OF PAYMENT: ❑CASH ❑ CHECK ❑ VISA 0 MC CARD # AUTHORIZED SIGNATURE: DATE EXPIRES SUBTOTAL PROCESSING FEE $35.00 TOTAL PERMIT FEE DUE: REVISED S/26/05 Permit Center Spokane 11707 13 Sprague Avc, Suite 106 Valle Spokane Valley, WA 99206 IQ/ (509)688-0036 FAX- (509)688-0037 Community Development www apokanevallcv ni^_ cum Plumbing Permit Application ;_PERM1T.NUNIBER 1PERMITuFEE- r o Commercial ,Residential SITE ADDRESS 4iS s, Mc KU _ St .�; :. -:` _-t--. .:• _' ':o-_.1 :�:.-.:..a-s?".'. _ gownerx.... 3,--";<7i'.iE-_:: >:._. . - .a �,-._�,;.:�.�z-"��,T^--�-�r�'-:h�a "-� .. - - .,I Name. pin Y'o, 7 �C K ((M..S 4- Phone: 9 Z C/ - lc! / % C-� Fax Address' - City State Zip - ...R.. � -, ,,- �. res_ -• Con[Factor--f.�F,,:..-nz.:.-..r�`�'q�.�a �?..�>��a;i:-- .f -g"- ' - � �� `7r'rti"-.'ri a: �.r;..,_ �fer'�-, cc- ...3. •�src-� -��_>-.F_-' __ _ _ -z. ��>�:/_.':.-_ .:.�r'�%�= �;��'-"�`-�4sh;_kv: :,:= - ��s�'�.:_�:.?«% L- Name: Al i /--te elj S.a A 5 Phi yn bii'j Phone: Fax. Address: City State Zip License Na: CityBusinessLicense No: jC0 t •Lf,+.."6F�e In _v�ltIt Y:.a.` e5-.`"i.'Siil�i�- X z3 " .f ��-i�' s�6l G�3 .4.+ Name: Name: rqU� (-':�t±� Phone: Zi ir`4�97,—/ TUBS AUTHORIZED SIGNATURE: REVISED 8/2W05 DESCRIPTION OF WORK # OF UNITS X COST = TOTAL AMOUNT 1 TOILETS WATER CLOSET, BIDETS 2 X $6.00 = 1 7--- 2 URINALS X $6 00 = 3 TUBS Z— X $600 = 1 Z 4 SHOWERS (PER TRAP) BATH, STALL, ON-SITE BUILT X $6 00 = 5 SINKS LAVSBASINS, BAR, FLOOR, KITCHEN, LAUNDRY, UTILITY, JANITOR, PHOTO, X-RAY, FOOD, PREP/CULINARY MEAT LI X $6 00 = '-'J 6 DISHWASHER 1 X $6.00 = /L - 7 CLOTHES WASHER X $6 00 = / C:2 8 GARBAGE DISPOSAL X $600 = 9 WATER SOFTENER X 5600 = 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 X $600 = 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 = 1 ` 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 $600 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 Z 0 VISA ❑ MASTERCARD PROCESSING FEE $35.00 EXPIRES. TOTAL PERMIT FEE DUE: AUTHORIZED SIGNATURE: REVISED 8/2W05 APPRovED 8 101.71' I/ Scc,1e w Lo+44171P q 15 s://40/-42/2_ s -1-1C \S 1OOTE 1ti 6to 0 IN . 7)'