2000, 03-07 Permit App: 00001372 Sewer, Plumbing FixturesSpokane 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.
PRO
.TION
Job ddre�/ ..- / Dry e Sewer? Own0r's nage:
City: City/State:
Zip: Zip:
Parcel Number (if known):k
Phone:_
First-time contractors or home -owners p orming the installation must first contact the Utilities Division in person or via phone (456.3604)) before a
permit can be issued.
Contractor
C1)'
Name of Utilities Division person contacted:
CONTRACTOR INFORMATION
Sate contractor license
I P -q
1 / Contact ame:
Business address: /
City/State:r[Z�/ �� U1('A Zip:O Phone Number:
INTERIOR PLUMBING ALTERATIONS? (yes/no) circle one
Fill out the information in the table below ifapplicable**
Cont actor (if different from above)i Phone: q Z Z — 5L'I
Business Addre s: I City/State/Zip Qi
IliAJ G7 e-5 �n% tp
**For plumbing reversal fee information, see reverse side of this form.
FEE INFORMATION
Sewer Connection: Number of Buildings X (times) $100 (per bldg)
TOTAL FEE
• 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 sing bwnership, one permit is required
• Multiple buildings (apartments, industrial completes) * single ownership, one permit required per building connecting to the sewer.
(For situati covered here, call the County Division of Utilities @ 456-3604)
APPLICANT SIGNATURE�,` , `'` DATE:
a
Method of Payment:
❑ Cash ❑ Check ❑ Visa
Date:
Bankcard Number:
Authorized Signature:
❑ MasterCard
Expires:
❑ Discover Card
Spokane County Division of Building & Planning
1026 Nest Broadway Avenue ` Spokane WA 99260
Te?. No. (509) 456-3675 Fax No. (509) 156 4703 TDD No. (509) 324-3166
PLUMBING PERMIT APPLICATION
PROJECT
ADDRESS:
PERMIT
USE:
OWNER: PHONE: DAA_flNIE CONTACT
MAILING ADDRESS:
street city state zip
CONTRACTOR: c LICENSE: QjE'ST VJ-P
PHONE:
MAILING ADDRESS: C, 1 L C —e --e acr .5 K �1
street city state zip
PLUMBING FIXTURES ft OF
DESCRIPTION DETAIL UNITS
�ttin-
F1 E BI
COST
/UNIT
EQun1s
AMOUNT
B02 :
TOILETS
WATER CLOSETS, BIDETS
x
S6
=
$
B 3..
URINALS
x
S6
=
$
B0.4-:
TUBS
BATH, JACUZZI, SPA, GARDEN
x
$6
=
$
B05.
SHOWERS er trap)
BASE, STALL, ON-SITE BUILD
x
S6
=
S
BQ6 :
SINKS
LAVS/BASINS, BAR, FLOOR, KITCHEN,
LAUNDRY, UTILITY, JANITOR, PHOTO,
X-RAY, FOOD (PREP/CULINARY/MEAT)
x
S6
=
S
Bf}::
DISHWASHER
x
S6
=
S
B08 :
CLOTHES WASHER
X
S6
=
S
B09:
GARBAGE DISPOSAL/GRINDER
x
S6
=
$
B10 :
WATER SOFTENER
x
S6
=
$
B l:I::
ELECTRIC HOT WATER TANKS
(NOTE: if gas water tank, see mechanical)
X
S6
=
$
B12::
FLOOR DRAINS
AREA, CASE, COIL, TRENCH, CONDENSATE
X
S6
=
S
B13:
ROOF DRAINS/OVERFLOW DRAINS ea.
x
$6
=
S
B14::
FOUNTAINS, DRINKING
x
$6
=
$
B15::
WATER PIPING/DRAIN-WASTE-VENT/
INSTALLATION, ALTERATION, REPAIR,
REVERSALS
x
$6
BIb :
SEW AGE Ej EU I OR$
GRINDER, SUMP PUMP
x
$6
=
$
B17::
WATER USING DEVICES
ICE AND/OR COFFEE MAKER,
HOSE BIB, STEAMER, PROOFER,
CARBONATOR, SWAMP COOLERS
x
$6
=
$
S1$>
CROSS -CONNECTION DEVICES
VACUUM BREAKER, CHECK VALVE,
AND R.P.B.P.D. FOR: VATS, SUMPS,
TANKS, BOILERS, & SPRINKLER SYSTEMS
x
$6
=
$
INTERCEPTORS
GREASE TRAP, SAND TRAP,
CHEMICAL HOLDING TANK
x
$6
=
$
B20 :
MEDICAL GAS(per outlet/bottle station
NITROUS, OXYGEN
x
S6
=
S
821:
MISCELLANEOUS FIXTURES
x
$6
=
$
Method of Payment:
MV/SA EJ'+ ❑ DISCOVER
❑ Cash El Check ❑ �
FAXED PERMM WILL ONLYBE ACCEPTED WI771 PAYMENT OFA MAJOR CREDIT CARD
Date: Expires:
Bankcard Number:
Authorized Signature:
Subtotal
PLUS: PROCESSING FEE
$25.00
TOTAL PERMIT FEE DUE
5
�LIII�IAIZJM:P.ERMIT FEE:IS h5.f)0:
:::PLEASE MAKE CHECKS:PAYABLE TO.. .
ANE: COi1NTX P)~RMI:T:C:ENIER
12/19/97 muter\plumbperm.hr
Spokane County Division of Building Planning
1026 West Broadway Avenue * Spokane WA 99260
Tel. No. (509) 456-3675 * Fax No. (509) 324-3198 * TDD No. (509) 324-3166