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2006, 05-02 Permit App: 06001471 ResidenceProject Number: 06001471 Inv: 1 Application THIS IS NOT A PERMIT Penalties will be assessed for commencing work without a permit Date: 5/2/2006 Page 1 of 3 Project Information: Permit Use: sfr, gas heat, on sewer Contact: OBEREMOK, TIMOFEY Address: 4519 E 5TH AVE C - S - Z: SPOKANE VALLEY, WA 99212 Setbacks: Front Left: Right: Rear: Phone: (509) 468-1523 Group Name: Site Information: Project Name: Plat Key: Name: Range District: Sout Parcel Number: 35232.3112 SiteAddress: 4515 E 5th AVE Location:: CSV Block: Lot: Owner: Name: OBEREMOK, TIMOFEY Address: 4515 E 5TH AVE SPOKANE VALLEY, WA 99212 Zoning: UR -3.5 Urban Residential 3.5 Water District: Hold: ❑ Area: 8,775 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 Originally Released: Landuse/Zoning/HE Conditions 5/2/2006 By: TMELBOU Sewer Review Originally Released: 4/26/2006 By: HMStinson Originally Released: 4/28/2006 By: amblake Permits: Operator: AMB Printed By: AMB Print Date: 5/2/2006 Project Number: 06001471 Inv: 1 Application THIS IS NOT A PERMIT Penalties will be assessed for commencing work without a permit Date: 5/2/2006 Page 2 of 3 Contractor: OWNER Description Gtr Tvpe Notes 1&2 FAMILY R-3 VB BASEMENT F R-3 VB BASEMENT U R-3 VB DECK OPEN R-3 VB GAR WOOD U-1 VB Item Description RESIDENTIAL PERMIT FEE WSBC SURCHARGE SF PLNS RVW < 7999 SQ FT Contractor: OWNER Item Description DUCT SYSTEMS GAS WATER HEATER GAS APPLIANCE<=100,000BTU AIR CONDITIONER:4-15 TONS VENTILATING FANS CLOTHES DRYER RANGE HOOD -TYPE II Contractor: OWNER Operator: AMB Building Permit Finn: OWNER Phone: (000) This Application: So Ft Valuation 1,120 $96,734.40 120 $2,400.00 507 $7,605.00 120 $1,800.00 532 $10,108.00 Totals: 2,399 $118,647.40 Units 1 1 1 Unit Desc SELECT SELECT SELECT Permit Total Fees: Mechanical Permit 000-0000 Total Project: Sq Ft Valuation 1,120 $96,734.40 120 $2,400.00 507 $7,605.00 120 $1,800.00 532 $10,108.00 2,399 $118,647.40 Fee Amount $1,100.15 $4.50 $440.06 $1,544.71 Firm: OWNER. Phone: (000) Units Unit Desc 1 NUMBER OF 1 NUMBER OF 1 NUMBER OF 1 NUMBER OF 3 NUMBER OF 1 NUMBER OF 1 NUMBER OF 1 NUMBER OF Permit Total Fees: Plumbing Permit 000-0000 Fee Amount $10.00 $10.00 $12.00 $20.00 $30.00 $10.00 $10.00 $10.00 $112.00 Firm: OWNER Phone: (000) 000-0000 Printed By: AMB Print Date: 5/2/2006 Project Number: 06001471 Inv: 1 Application THIS IS NOT A PERMIT Penalties will be assessed for commencing work without a permit Date: 5/2/2006 Page 3 of 3 Notes: CONTROL AREA FOR DRAINAGE MORITORIUM SEE MAPS FOR SPECIFICS Payment Summary: Permit Type Building Permit Mechanical Permit Fee Amount $1,544.71 $112.00 Invoice Amount $1,544.71 $112.00 Amount Paid $0.00 $0.00 Amount Owing $1,544.71 $112.00 $1,656.71 $1,656.71 $0.00 $1,656.71 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: AMB Printed By: AMB Print Date: 5/2/2006 Proje t Number: 06001471 Inv: 1 Application THIS IS NOT A PERMIT Penalties will be assessed for commencing work without a permit Date: 4/21/2006 Page 1 of 2 Project Information: Permit Use: sfr, gas heat, on sewer Contact: OBEREMOK, TIMOFEY Address: 4519 E 5TH AVE C - S - Z: SPOKANE VALLEY, WA 99212 Setbacks: Front Left: Right: Rear: Phone: (509) 468-1523 Group Name: Site Information: Project Name: Plat Key: Name: Range Parcel Number: 35232.3112 Block: Lot: District: Sout SiteAddress: _E_ Stir Owner: Name: OBEREMOK, TIMOFEY Address: E 5TH AVE Location:: OSSV-" )7 ,C SPOKANE VALLEY, WA 99212 Zoning: UR -3.5 Urban Residential 3.5 Water District: Hold: ❑ Area: 8,775 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 I Released By: Landuse/Zoning/HE Conditions Sewer Review Permits: Released By: /4,4 Released By: Building Permit Contractor: OWNER Firm: OWNER Phone: (000) 000-0000 Mechanical Permit Contractor: OWNER Firm: OWNER Phone: (000) 000-0000 Operator: AMB Printed By: AMB Print Date: 4/21/2006 35232.3110 PARCEL NUMBER REQUESTED BY: (Please Print) OWNER NAME: SITUS ADDRESS CHANGE AUTHORIZATION FORM SPOKANE COUNTY ASSESSOR'S OFFICE —T-1)2 416 M.I0HAE L Last 013Ei�E imOK, T 1 First J. Middle DATE OF REQUEST: ` Ian /02010 REQUESTER'S PHONE NUMBER: 5o1 £ E33 . 002S- PLEASE 03fPLEASE PROVIDE DESCRIPTION OF REAL PROPERTY ON REVERSE SIDE OLD SITUS ADDRESS: NEW SITUS ADDRESS: SSI ,S e. s*h Av AUTHORIZING SIGNATURE: OFFICIAL USE ONLY BUILDING / PLANNING APPROVAL: ASSESSOR OFFICE INITIALS: PLEASE PROVIDE DESCRIPTION OF REAL PROPERTY BELOW 1 1 Sly COURrY SPOKANE COUNTY DEPARTMENT OF BUILDING & PLANNING 1026 WEST BROADWAY AVENUE • SPOIG&NE, WA 99260-0050 Site Information Site Address: 4515 E 5TH AVE Parcel Number: 35232.3112 Subdivision: CARNHOPE ADD Block: 2 Lot: 10 Zoning: UNK Unknown Owner: OBEREMOK, TIM & ZHANNA Address: 418 E PINE NEEDLE COLBER, WA 99005 Building Inspector: NONE Water Dist: Project Information Project Number: 06002620 Inv: 1 Issue Date: Permit Use: SEWER CONNECTION - CARNHOPE ADD 1 5/1/2006 Applicant: OBEREMOK, TIM & ZHANNA 418 E PINE NEEDLE COLBER, WA 99005 Phone: (509) 868-3621 Contact: OBEREMOK, TIM & ZHANNA 418 E PINE NEEDLE COLBER, WA 99005 Phone: (509) 868-3621 Setbacks - Front: Left: Right: Rear: Group Name: Project Name: 1 Permits Sewer Connection Permit Contractor: FOX DIRTWORK License#: FOXDIDW976MQ SEWER CONNECTION 1 $85.00 PROCESSING FEE 1 515.00 Total Permit Fee: $100.00 FOR SEWER INSPECTIONS CALL THE UTILITIES DEPT AT (509) 477-3604 FROM 8:30-5:00 MONDAY -FRIDAY PRIOR TO COVER. ONE WORKING DAY NOTICE REQUIRED. PERMIT ALLOWS FOR A 30 -MINUTE INSPECTION. ADDITIONAL INSPECTION FEES APPLY AFTER 30 MINUTES. THE INSTALLER IS RESPONSIBLE TO INSURE ALL WASTEWATER DRAINS ARE CONNECTED TO THE SEWER AND MAY BE REQUIRED TO PERFORM TESTS FOR VERIFICATION. INSTALLER IS TO FIELD LOCATE AND CONFIRM THE ELEVATION AND POSITION OF SEWER STUB PRIOR TO ANY OTHER EXCAVATION. SEWER STUBS ARE TO BE CHECKED PRIOR TO CONNECTION TCfENSURE THAT THEY HAVE ACCEPTABLE GRADE AND ARE CLEAR AND UNOBSTRUCTED TO THE MAIN..SEWER LINES SHOULD BE CONSTRUCTED TO ALLOW FOR GRAVITY FLOW FROM THE LOWEST LEVEL OF THE STRUCTURE. THE INSTALLER AND THIS PERMIT MUST BE PRESENT AT THE JOB SITE AT THE SCHEDULED INSPECTION TIME. BOTH STATE LAW RCW 19.122 AND COUNTY CODE REQUIRES THE INSTALLER TO GIVE NOTICE OF EXCAVATION TO OWNERS OF UNDERGROUND FACILITIES. CALL 1-800-424-5555 BEFORE YOU DIG --AT LEAST 2 WORKING DAYS IN ADVANCE. SPOKANE COUNTY CODE REQUIRES THE INSTALLER COMPLY WITH ALL REQUIREMENTS OF THE WA STATE DEPT OF LABOR & INDUSTRIES, INCLUDING THOSE RELATED TO TRENCH SAFETY. 1 Payment Summary Total Fees AmountPaid AmountOwing $100.00 $100.00 $0.00 Tran Date 5/1/2006 Processed By: SHATTO, JULIE Printed By: WENDEL, GLORIA Page 1 of I Receipt # Payment Amt 2123 $100.00 PERMIT NOTICE 1t is the responsibility of the applicant/permittee to see that the use described on the front of this permit complies with applicable codes and requirements and that required inspections are requested. Failure to request inspections as listed below and obtain the necessary approvals before progressing beyond the point where inspections are required may necessitate removal of certain parts of the construction at the applicant's/permittee's or property owner's expense. At a minimum, the following inspections ARE REQUIRED by County Code: 1. FOOTING - when forms and reinforcement are in place and prior to placement of concrete—all structures, including manufactured homes. NOTE: This inspection includes review of the structure's setbacks from property lines. Minimum setbacks are established by County zoning regulations. Typically, side and rear yard setbacks are measured from property lines, while setbacks for yards abutting streets are measured from the property line or the center line of the roadway right-of-way, whichever provides the greater setback from the center line of the roadway right-of-way. Curb lines and fence lines are not necessarily indica- tive of property lines. In some residential areas, the County can own as much as 20 feet of right-of-way between your property and the actual improved street/curb. The responsibility to comply with applicable setback provisions lies solely with the permittee—neither Spokane County nor its authorized representatives assume any responsibility for the verification or location of your property lines. Please verify their location prior to locating your structure. Failure to properly locate the structure may require its relocation at the owner's/permittee's expense. 2. FOUNDATION - when forms and reinforcement are in place and prior to placement of concrete. 3. FRAMING - after all framing, bracing and blocking is in place, and prior to concealing. 4. INSULATION - prior to the installation of drywall. 5. PLUMBING - after rough -in, before covering, and final. 6. MECHANICAL - rough -in of piping, before covering, metal chimneys before concealment, and final. 7. FINAL - when complete and prior to occupancy and/or use. Please provide 24 hours notice. 511 permits require final inspection. NOTE: In addition to inspection of the structure, this inspection includes review of site improvements (typically depicted on the approved site plan) required by ordinance or as a condition of approval of this permit. Items such as the installation of fire hydrants, fire department access, on-site drainage ("208 swales"), road improvements, parking, and landscaping are common requirements of a permit/site plan which must be completed prior to final approval of a building or issuance of a Certificate of Occupancy. 8. MANUFACTURED HOMES -Final inspection required when complete, stairs, handrails, skirting, etc. installed, and prior to occupancy; completed inspection record card must be available on site. Manufactured home installations must comply with the manufactures installation instructions. 9. SEWERS - prior to cover 10. RIGHT-OF-WAY/APPROACH - prior to placement of concrete, or, if gravel approach, after completion. In addition to the above, any plumbing or mechanical systems or material which would be concealed by framing, drywall, concrete, etc., must be inspected prior to cover. Check with the department for "special inspections" in conjunction with commercial projects. FOR INSPECTIONS: TO INSURE PROMPT SERVICE, PLEASE GIVE ONE WORKING DAY/24 HOUR NOTICE . PARTS OF YOUR PROJECT MAY REQUIRE PERMITS AND INSPECTIONS FROM MORE THAN ONE AGENCY. • Building, plumbing, mechanical and fire inspections, Department of Building and Code Enforcement 477-3675 • Construction in a flood plain, Division of Engineering & Roads 477-3600 • Electrical wiring, State Department of Labor and Industries 324-2640 • On-site waste disposal system, Spokane Regional Health District 324-1560 • Road cuts for utilities or driveways, Division of Engineering & Roads - 48-HOUR NOTICE REQUIRED 477-3600 or State Department of Transportation 456-3000 • Sewer connection, Division of Utilities 477-3604 or City Public Works Department 625-6300 PERMIT EXPIRATION AND REFUNDS Unless otherwise noted, this permit will be considered null and void by limitation if the work authorized by the permit is not commenced or is stopped for a period of 180 days, unless a written request for an extension of the permit is received and approved by the Building Official prior to expiration. At a minimum an inspection should be requested at least once every 180 days to assure the validity of the permit. A permit may be renewed within one year of the date of expiration for one-half the original fee, subject to certain limitations—please call us if you have any questions. Any refund requests must be made in writing by the applicant/permittee (shown on the reverse) no later than 180 days after the date of fee payment. Refunds of not more than 80% of the permit fee paid may be authorized when no work has been done under the permit. No refunds may be authorized more than 180 days after fee payment. MISTAKE? If you think we've made an error in processing this permit or in conducting inspections pertaining to it, or find erroneous information in the permit, please bring it to our attention immediately by filing a written request for correction within 10 working days of discovery. All such requests should be directed to the Division of Building and Code Enforcement at the below address. Spokane County Department of Building and Planning 1026 West Broadway Avenue, Spokane, WA 99260 Phone: (509) 477-3675 Fax: (509) 477-4703 TDD: (509) 477-7133 www.spokanecounty.olg/bp bp@spokanecounty.org FORA( wmm ei.00 VEA/AT V}F!J.r iZc 1 1 v i c ,>piague live, Juice 1 Ub Valle7� Spokane Valley, WA 99206 * lI y (509)688-0036 FAX: (549)688-0037 Cor'rnunity Development 7.7'x.")ok 'Ieva/1e .ora.00m D C [EDVg Residential Construction APX Permit Application 1-[--).\‘ 1D SITE ADDRESS /"i.6(q E. 5 X1'1 Av-e.. rbxN11 NUMBER (4-71 PERMIT FEE: Construction o Accessory Bldg dition/Remodel ❑ Deck &okan61cklle I L q 'Z ASSESSORS PARCEL NO: 3 rj d 3a 3 1 I vQ LEGAL DESCRIPTION: t vest co r n ho amt or t of 9 Lt) (5 f. 'oF t tet- t0 .Contractor, Building owner1:.."!-I, .r Name:Tim and 7hoymbc. Ob xernok Address: y\$ E. Vine, N-eedte City: Qc Wbex't vx) Pk- Zip: q gOO5 Phone<560LAJS123 Fax: (56 0 4402 -152 Con,fact Person ,, ^ Name: hojina Oberernor_ Phone: (561) 81215 152Z e 5 1 $= 3021 Name: Address: City: Phone: Fax: Lic No: Exp. Date: City Business Lic No: Describe the scope of work in detail: Cost of Project: l $ S 1n31Q} reld. x e s�l��- x1ela ()Y) em CA j to 0 **************The followin HEIGHT TO PEAK MAIN FLOOR TO SQ. FTG: ' U o t� FINISHED BASEMENT SQ. FTG: 120 # OF BEDROOMS: 3 DISCLAIMER 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 hi 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 g DIMENSIONS: 40's. 2l0 MUST be complete: 2"" FLOOR SQ. FTG: GARAGE SQ. FTG: Sze- S 3 ?— CONSTRUCTION TYPE: Spic+ level (write N/A if not app # OF STORIES: S 1vt \€ Qt UNFIN BASEMENT SQ. FTG: licabier********************* So 7 TOTAL ABIfT B E SPACE �d�s /6Z - IMPERVIOUS SURFACE AREA: DEC HEAT SO RCE: 30% SLOPES ON PROPERTY: /V0 SEWER OR SEPTIC? Signature Rex Date "T-1--2.600 Method of Payment: (Fa d rmit adplications will only be accepted with major bankcard) 0 Cash Check ❑ Mastercard 0 VISA Bankcard #: Expires: . VIN#: Authorized Signature: REVISED 8252DD5 0 Other S°e Talley 11707 E Sprague Ave Suite 106 ♦ Spokane Valley WA 99206 09.921.1000 ♦ Fax 509.921.1008 ♦ cityhallespokanevalley.org Residential Pian Submittal Minimums ❑ Completed Building & Mechanical application with: Accurate' address, Parcel Number and/or Legal Description, description of work, owner and contractor information, signature, and date. ❑ Two sets of plans including Site Plan, elevations, floor plans, foundation plans With details, roof plan, framing plans & details. ❑ Show the height of any proposed buildings or accessory structures. O Floor plan for each floor. Dimension to scale (minimum 1/81 and label each Room (including sq. footage of house and garage on plans) Show each level of existing house and square footage of any additions. ❑ All braced wall panel types: show locations and details of installation, including engineered design. O Egress windows: Provide at least one window or exterior door approved for Emergency escape or rescue from a basement and in every room for sleeping. ❑ Smoke detector locations O 22' X 30' attic access location 0 18' X 24' crawl space access: ❑ One-hour separation dptail: between house and garage ❑ Floor framing details: Joist type, size, spacing and installation details ❑ Roof framing plan and details ❑ Fumace and hot water heater location. . ❑/ All header locations: type, size, and connections I Foundation plan o Insulation information Permit Center Spokane ® 11707 E Sprague Ave, Suite 106 Spokane Valley, WA 99206 (509)688-0036 FAX: (509)688-0037 Community Development www.snokanevallev.org Mechanical Permit Application ❑ Commercial SITE ADDRESS: PERMIT NUMBER: PERMIT FEE: Residential Nak Mara Building Ohf* Th- ' i- fhann0. Obereoce . ... ....:�' :.... .. Name: Phone: Fax: (5�) -ROW: t 22) Address L.4tR E Nit Neste �5�00i y�1k1E�•1523 ZIP COBS State: I D& City:�-f 'r4 _. ... Name © Phone: �Q1 Far I LJ"') C{�Q-d -( 573 Address p. `t� 1�Y� 22aa City:State: ,,`C`L� P j-- zip: Tab License No:..e-- City Business Lic: Contact. . -baennkb ..• . ^, Name: - Phone: 'Q 7 a162.3 75 0 &8 -30-1 DESCRIPTION OF WORK A OF UNITS X COST = TOTALAMOUNT 1 FUEL BURNING APPLIANCE Equal to or less than 100,000 1 X $12.00 2 FUEL BURNING APPLIANCE More than 100,000 X $15.00 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 0 USED APPLIANCE (W SEC 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 I 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 15 FUEL BURNING WATER HEATER 1 X $10.00 18 MISC. FUEL BURNING APPLIANCE X $10.00 17 GAS PIPING (each outlet) X $1.00 18 DUCT SYSTEMS 19 VENTILATING FANS IW 20 AIR HANDLER (DOES NOT include ducting) Equal to or less than 10,000 CFM 3 X $10.00 X $10.00 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 25 HEAT PUMP/AIR CONDITIONER 0-3 TON 1 X $10.00 X $12.00 26 AIR CONDITIONER 3115 TON X $20.00 27 AIR CONDITIONER 1530 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 8 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 F AYMENT: ❑CASH CHECK ❑ VISA 0 MC CARD it: AUTHORIZED SIGNATURE: REVISED 8/21:N5 EXPIRES: VIN: SUBTOTAL PROCESSING FEE $35.00 TOTAL PERMIT FEE DUE: Permit Center S"ne 1 11707E Sprague Ave, Suite 106 Spokane Valley, WA 99206 (509)688-0036 FAX: (509)688-0037 Community Development www.spokanevallev.org Plumbing Permit Application n Commercial Residential SITE ADDRESS: vee vaLl� wrt- Building Owner y,,�/� y,, p� Name: `�l�n`i �-� .7 LnJ L� j1 ' — Phone: Q(J8/ 2 L/ $ L S3 �11 Address: ` y E T , Q • N .4' . City: W�) State: Zip CO3 �`�� Contractor Name: +t/% (67/010r) Phone: Fax: Address: City: State: Zip: License No: City Business Lic: Confect Ack .. -aerA Phone: V %f�% (-\..61tiW ir j � %�Name: G 5�? a v`4 DESCRIPTION OF WORK # OF UNITS X COST TOTAL AMOUNT 2 3 TOILETS URINALS TUBS WATER CLOSET, BIDETS X $6.00 X $6.00 X $6.00 4 5 6 SHOWERS PER TRAP SINKS DISHWASHER BATH, STALL, ON-SITE BUILT X 7 CLOTHES WASHER LAVS/BASINS, BAR, FLOOR, KITCHEN, LAUNDRY, UTILITY, JANITOR, PHOTO, X-RAY, FOOD PREP/CULINARY MEAT 4o X X $6.00 $6.00 $6.00 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 021 X $6.00 11 FLOOR DRAINS AREA, CASE, COIL, TRENCH, CONDENSATE 1 X $6.00 12 ROOF DRAINS/OVERFLOW DRAINS X $8.00 13 FOUNTAINS, DRINKING X $6.00 14 WATER PIPING/DRAIN-IN WASTE. VENT, PLUMBING, REVERSAL NSTALLATION, ALTERATION, REPAIR, REVERSALS X $6.00 15 16 17 SEWAGE EJECTOR WATER USING DEVICE CROSS CONNECTION DEVICE GRINDER, SUMP PUMP ICE AN/OR COFFEE MAKER, HOSE BIB, STEAMER PROOFER. CARBONATOR, SWAMP COOLER VACUUM = REAKER, CHECK VALVE, AND R.P.B.P.D. FOR: VATS, TANKS, BOILERS 18 INTERCEPTORS GREASE TRAP, SAND TRAP, CHEMICAL HOLDING TANK X X X $6.00 $6.00 $6.00 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 CHECK ❑ VISA ❑ MC Card# / J AUTHORIZED SIGNATURE: REVISED &/26/05 EXPIRES: VIN: SUBTOTAL PROCESSING FEE $35.00 TOTAL PERMIT FEE DUE: (5 4 A $D 4-- PLANNING DEPT. APPROVED BY' DATE: a bl, 40' X (Pi New Cori sqruc-fia� single -Pami7y rc.fic%hc6 E. 51+1 Ave. SkzkaneValky Aye. dTee) •�