2004, 02-19 Permit App: BLD-04-03583 Mechanical Fixtures Spokane County Division of Utilities
SEWER CONNECTION PERMIT APPLICATION FORM
PLEASE NOTE: This application form must be filled out accurately and in its entirety,and signed,or a permit will not be issued. Also note that sewer
permits are valid for 12 months form the date of issuance. No extensions will be granted. A separate right-of-way permit is required for any work
performed in or from the county right-of-way.
l l PROJECT INFORMATION
Job Address: 101 "l/1 N• RU,A.01 T Owner's name: //62 11/1/4774
//1/G/ �Lrie LZCSl'i
Parcel Number I 1 Z` 1331 5k:
Project Name: wal n w'� Address: /% u. 2OX 131 l
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I//t�l«/ i"
City/State:
CHECK APPLICABLE BOXES �,��} 7
�{ Zip: 1 1r�L/J
J Regular N Residential 0 New
U Dry Sewer 0 Commercial O New SO 9/92V.23A2
LiRepair 0 Temporary Phone:
❑ Addition
U Abandonment
* FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMING THE INSTALLATION MUST FIRST CONTACT THE
UTILITIES DIVISION BEFORE PERMIT(S)CAN BE ISSUED. d
SIGNATURE OF UTILITIES DIVISION PERSON CONTACTED:OK J"�7\v�Mt/t•a Z/io/4
Cazzlm /we"iri f , t3 Sate contractor number
b E/`ic , 1
Business address: ^L d' 3"`(s." Contact 1,&
City/State--(A/ / - dizzEZWZip:7q)
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Phone Number.
INTERIOR PLUMBING ALTERATIONS? es 'n6) circle one
Fill out the information in the table below if applicable**
Contractor(if different from above): Phone:
Business Address: City/State/Zip
FEE INFORMATION
Number of Buildings connecting to sewer ` X(times)$100(per bldg)=$ I° ' +.4rn�
RIGHT OF WAY PERMIT
• For a single-family residential unit,one permit is required;
• For a condominium,townhouse,duplex,triplex or fourplex with separate ownership(as determined by lot lines)separate address and separate stub,one permit is required per address per stub;
• For a single building duplex,triplex or fourplex with single ownership,one permit is required
• Multiple buildings(apartments,industrial complexes)with single ownership,one permit required per building connecting to the sewer.
(FOR SITUATIONS NOT COVERED HERE,CALL THE COUNTY DIVISION OF UTILITIES AT 477-3604)
Is any of the work to be performed in or from the&tit:5T right-of-way? 0 Yes 0 No
APPLICANT SIGNATURE: DATE:
Method of Payment:
O Cash D Check 0 Visa 0 MasterCard 0 Discover Card
Date: Expires:
Bankcard Number.
Authorized Signature:
Spokane County Division of Building&Code Enforcement
1026 West Broadway Avenue*Spokane WA 99260
Tel.No.(509)477-3675*Fax No.(509)477-7198*TDD No.(509)477-7133
PLUMBING PERMIT APPLICATION 04 _ 3 s- 3
..
PROJECT ` PERMIT
/'
ADDRESS: 9/9 4/ fe/�L/DC)( /� USE:
OWNER:�y - PHONE (Daytime Contact): � g !7tl ,J)vDc/y����E , G-L-c- � _
MAILIN
.04OrB /3/1/ cf ) `/6 ' t.4 , telr
(Street) (City/State)
(Zip)
CON CTOR: r LICENSE:
Arolf
MAILING ADDRESS: PHONE:
. ,,,t9A �./,.?./// ssp /6g/ii{ y, 424 7c92/3
(Street) (City/State) (Zip)
PLUMBING FIXTURES I I
#OF MULTI- COST/ AMOUNT
DESCRIPTION DETAIL UNITS rByn UNIT EQUALS
802 TOILETS WATER CLOSETS,BIDETS x $6 =
� URINALS x $6 =
; TUBS - x $6 =
141*-, SHOWERS(per trap) BATH,STALL,ON-SITE BUILD x $6 =
kW SINKS LAYS/BASINS,BAR,FLOOR, x $6 =
KITCHEN,LAUNDRY,UTILITY,
AV JANITOR,PHOTO,X-RAY,FOOD
4,::' (PREP/CULINARY/MEAT
M ; DISHWASHER - x $6 =
Alt CLOTHES WASHER - x $6 =
IVO', GARBAGE DISPOSAL/GRINDER - x $6 =
0` WATER SOFTENER - x $6 =
B, ELECTRIC HOT WATER TANKS (NOTE: if gas water tank see mechanical) x $6 =
BIZ': FLOOR DRAINS AREA,CASE,COIL,TRENCH, x $6 =
CONDENSATE
TAW ROOF DRAINS/OVERFLOW DRAINS(ea.) - x $6 =
DO FOUNTAINS,DRINKING - x $6 =
BV WATER PIPING/DRAIN-IN WASTE- INSTALLATION,ALTERATION, x $6 =
,. . V VENT/PLUMBING REVERSALS REPAIR,REVERSALS
81 ,>". SEWAGE EJECTORS GRINDER,SUMP PUMP x $6 =
BITWATER USING DEVICES ICE AND/OR COFFEE MAKER,HOSE x $6 =
-,
:f:;= BIB,STEAMER,PROOFER,
; CARBONATOR,SWAMP COOLERS
R4*,' CROSS CONNECTION DEVICES VACUUM BREAKER,CHECK VALVE, $6 =
le< AND R.P.B.P.D.FOR: VATS,SUMPS,
A TANKS,BOILERS,&SPRINKLER
tax-
SYSTEMS
INTERCEPTORS GREASE TRAP,SAND TRAP, x $6 =
V CHEMICAL HOLDING TANK
;' „ MEDICAL GAS(per outlet/bottle station) NITROUS,OXYGEN x $6 =
,..�„? MISCELLANEOUS FIXTURES $6 =
METHOD OF PAYMENT SUBTOTAL
'ia , t PLUS PROCESSING FEE $ 25.00
❑ CASH 0 CHECK 0 0 _ ._} 0
FAXED PERMITS WILL ONLY BE ACCEPTED WITH PAYMENT
OF A MAJOR CREDIT CARD TOTAL PERMIT FEE DUE 17,(
DATE: EXPIRES: a Fes: :r ,' V V�� =.1E ' F;;
BANKCARD NUMBER ` R yIa qs
AUTHORIZED SIGNATURE: ei�'''#� �` - � � ��f' ��� ,:
Spokane County Division of Building&Code Enforcement
1026 West Broadway Avenue*Spokane WA 99260
Tel.No.(509)477-3675*Fax No.(509)477-7198*TDD No.(509)477-7133