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