Loading...
2000, 03-14 Permit App: 00001596 Sewer, Plumbing Reversal 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 chat sewer permits are valid for 12 months form the date of issuance. No extensions will be granted. W wPROJECT INFORMATION 1 59 SC Job Address: I/ I/ 6 4''1 '" Owner's name: _ , V / 4 Parcel Number: Lot: Block: //�� / /�jj7 � Address: 2f j CHECK pN ABLE BOXES I l Residential 0 New City/State: �1 • % - Regular ❑ Dry Sewer 0 Commercial 0 New Zip: 77e207 ❑ Repair 0 Temporary O Addition .. '' Phone: —/� ❑ Abandonment FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMING THE INSTALLATION MUST FIRST CONTACT THE UTILITIES DIVISION BEFORE PERMIT(S)CAN BE ISSUED. • SIGNATURE OF L=11 is S DMSION PERSON CONTACTED: OP illit , CONTRACTOR INFORMATION Contractor(company name): Sate contra .or license number: �� P . Nin P l E-1t-- NAY z e-f'. w (3 Business address: Contact Name:,-60 0 N A P 1E- g- Q Cicr/State: Zip: Phone Number: "l/l 8 75 41," INTERIOR PLUMBING ALTERATIONS.W)circle one Fill out the information in the table below if a• % e** Contractor(if different from above): Phone: Business Address: City/State/Zip _ 9���)^ 4-12 ,7 ' 4 ! �1�'I iVi,%— GLS rte, ,/,‘?4_,-- 99,49.9,4:2 **For plumbing reversal fee information,see reverse side of this form. FEE INFORMATION Number of Buildings connecting to sewer / X(times) SIC0(per bldg) = S //972> vv TOTAL • Fora single-family residential unit,one permit is required: • Fora 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 pe.•stub; • For a sin;ie 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:he sewer. (FOR SITUATIONS NOT COVERED ERE,CALL TH -COUNTY DIVISION OF UTILITIES AT 477-3604) `f.„PLICANT SIGNATURE: / - ATE: ri ji•r ��� Method of Payme�ny. ❑ Discover Card O Cash Qd Check 0 Visa 0 MasterCard Date: Expires: Bankcard Number: Authorized Signature: Spokane County Division of Building&Planning 1026 West Broadway Avenue*Spokane WA 99260 Tel.No.(509)477-3675*Fax No.(509)477.4703*TDD No.(509)324-3166 PLUMBING PERMIT APPLICATION PROJECT _ PERMIT / / /� ADDRESS: ���Y/' =�/51/A-7-- USE: �s � OWNER: �y ) I PHONE (Daytime Connct MAILING ADDRESS: fh — l ,hG9,X /� (Street) h_24--- 'mss, (city/state) (Ziol CONTRACTOR: LICENSE: MAILING ADDRESS: PHONE: (Street) (City/State) (Zip) PLUMBING FIXTURES i #OF 34(.1;7 COST./ AMOUNT PL'ED DESCRIPTION DETAIL UNITS sy UNIT EOCILS 300 TOILETS. WATER CLOSETS.BIDETS I x I So - I 303 URINALS I I I x I So - 303 TUBS I BATH.STALL.ON-SITE BUTT D I I x I So I - I I 305 SHOWERS.cer trao) • I I x I SO - BCo SINKS LAVS/B;SUMS,BAR,FLOOR, x So - KITCHEN,LAUNDRY.UTILITY, JANITOR,PHOTO,X-RAY,FOOD (PREP/CULINARY/MEAT BC7 D LS1-.7W AS HER I - I I x I So BCS CLOTHES WASHER I I x So - BC9 GARBAGE DISPOSAL/GRINDER I - I I x I S0 + - 310 WATER ER SOFTENER (NOTE: ii gas water tank see x SO - mechanical) B11 ELECTRIC HOT WATER TANKS AREA.CASE.COIL,TRENCH, I x So G - CONDENSATE 13:0 FLOOR DRAINS - I I x I So - 313 ROOF DRAINS/OVERFLOW DRALNS - x So - (ea.) 314 FOLD TALNS.DRI KING 1 I x i 50 I - 315 WATER?II'ING/DRALN-]NI WASTE- LNSTALL •a., - TE' ATION, x So VENT/PLUMBING REVERSALS REP. I' REVE'SALS 310 SEWAGE EJECTORS I GR+NDE'• • IP I I x I So - 317 WATER USING DEVICES •ICE AND/OR COFFEE MAKER, x SO - HOSE BIB,STEAMER,PROOFER, CARBONATOR.SWAMP COOLERS B:S CROSS CONNECTION DEVICES VACUUM BREAKER,CHECK SO - VALVE,AND R.P.B.P.D.FOR: VATS,SUMPS,TANKS,BOILERS,& SPRLNYI FR SYSTEMS B19 INTERCEPTORS GREASE TRAP,SAND TRAP, x So CHEMICAL HOLDING TANK 320 MEDICAL GAS(per outlet/bottle station) I NI11.&OUS.OXYGEN I :c I SO I - B-1 MISCELLANEOUS FIXTURES 1 I I 56 I - METHOD OF PAYMENT SUBTOTAL VISA JII�1fEf. PLUS PROCESSING FEE 5 225.00 ❑ CASH ❑ CHECK 0 0 0 7:. , FAD PERMITS WILL ONLY SE ACCEPTED WITH PAYMENT OF A MAJOR CREDIT CARD TOTAL PERMIT FEE DUE DATE: EXPIRES: MINLVIM PERMIT FEE IS$35.00 PLEASE MAKE CHECKS PAYABLE TO BANKCARD NUMBER: SPOKANE COUNTY PERMIT CENTER AUTHORIZED SIGNATURE: Spokane County Division of Building&Planning 1026 West Broadway Avenue`Spokane,WA 99260-0050 Telephone No.(509)477-3675*Fax No. 324-3198*TDD No. (509)324-3166