2005, 04-07 Permit App: 05001095 Plumbing ReversalPLUMBING PERMIT APPLICATION
Phone: (509) 688-0036; FAX: (509) 688-0037
For Inspections, Call (509) 688-0054
Project Address: 69 /)\�
• Owner. OMS -,M-,--
Mailing Address: S
Permit Use:
Community Development Department
Building Division
11707 E, Sprague Avenue, Suite 106
Spokane Valley, WA 99206
Phone (Daytime Contact): ctg 4
- Contractor. D cn, „rcd.,
Maiing Address: IRgyfc S ,,, r,,.,
City
License #:
State Zip Code
Phone #: '
City
St to
Zip Code
BANKCARD NUMBER:
AUTHORIZED SIGNATURE a
DESCRIPTION OF WORK
5 OF UNITS
X
. COST •
•
TOTAL AMOUNT
1
TOILETS
WATER CLOSE., BIDETS'
X
- $6.00 _
2
URINALS
%
56.00
3
TUBS
—'
X
56.00
=
4
SHOWERS (PER TRAP)
BATH, STALL ONSITE BUILT
X
$6.00
5
SINKS
LAVSBASINS, BAR, FLOOR, KITCHEN,
'LAUNDRY. UTILITY, JANITOR. PHOTO.
X-RAY FOOD,.PREPICULINARY MEAT
X
$6.00
e
DISHWASHER
X
56.00
7
CLOTHESWASHER
X
5600
•
8
GARBAGE DISPOSAL .
X
56.00
=
9
WATER SOFTENER
X
16.00
=
10
ELECTRIC HOTWATER TANK
NOTE IF GAS, SEE MECHANICAL
X
56.00'
_
11
FLOOR DRAINS
ARE4, CASE, COIL. TRENCH CONDENSATE
X
58.00
12
ROOF DRAINS/OVERFLOW
DRAINS
..
X
56.00
=
13
FOUNTAINS, DRINKING
X
56.00
=
14
WATER PIPING/DRAIN.IN WASTE.
VENT, PLUMBING, REVERSAL
NSTALL TION, ALTERATION, REPAIR,
.REVERSALS
X
56.00
•
15
SEWAGE EJECTOR
GRINDER, SUMP PUMP
X
56.00
=
16
WATER USING DEVICE
CE AN/OR COFFEE MAKER HOSE BIB,
STEAMER
PROOFER CARBONATOR SWAMP COOLER
_
X
56.00
=
17
CROSS CONNECTION DEVICE
' VACUUM -BREAKER, CHECK VALVE,
AND R.P.B.P.D. FOR VATS TANKS BOILERS
X
56.00
=
1B
INTERCEPTORS
GREASE TRAP, SAND TRAP.
CHEMICAL HOLDING TANK
X
58.00
_
19
MEDICAL GAS (per outlet)
- NITROUS. OXYGEN
X
56.00 -
_
20
MISCELLANEOUS PLUMBING
FIXTURE
X
56.00
=
21
PRIVATE SEWAGE DISPOSAL/SYS
-
X
$20.00
22
INDUSTRIAL WASTE
INTERCEPTOR
%-
515.00
•
METHOD OF PAYMENT:
CA0
�SH 0 CHECK
DATE
VISA 0 MASTERCARD
EXPIRES
SUBTOTAL
PROCESSING FEE
.505.00
TOTAL PERMIT FEE DUE:
BANKCARD NUMBER:
AUTHORIZED SIGNATURE a