2000, 03-13 Permit App: 00001561 Sewer, Plumbing Reversal Spokane County Division of Utilities ; / l (
SEWER CONNECTION PERMIT APPLICATION FORM 0 r
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.
PROJECT INFORMATION
Jobilc� ^ / -f�j D Sewer? Owner' a e: fi
61/6.ek&c/
City:
i7 J,%>9/q City/State:
Zip: / t Zip:
Parcel Number(if known): i -9= Phone: Wr
First-time contractors or home-owners performing the installation must first contact the Utilities Division in person or via phone[456-3604])before a
permit can be issued.
Name of Utilities Division person contacted:
CONTRACTOR INFORMATION
Contractor(company game): Sate contractor license number:
C� c-tA n e C--0a_R-e-C. -ie. 1 E I a-'1
(0c3ri E, I cL.1
Contact Name:
Business address: ,
4,t)`� t- ais1 e,
City/State:1 ��l ViI/Q Zip: q 9).-0(.0
Phone Number:
G214 -5'-15
INTERIOR PLUMBING ALTERATIONS? (yes/no) circle one
Fill out the information in the table below if applicable'*
Cont actor(if different from above)- Phone:
I -,-;h„trs pt urnh t r y G 22 -) 541
Business Addre s: City/State/Zip
/B41 to I lv' C--T f^e_en a:_re-S 1 WA a 90i
**For plumbing reversal fee information,see reverse side of this form.
FEE INF RMATION
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 tingle ownership,one permit is required
• Multiple buildings(apartments,industrial complex. with single ow = ship,one permit required per building connecting to the sewer.
or situations •of covered he • I the County i ivision of Utilities @ 456-3604)
APPLICANT SIGNAT • /_// �/-/ -/ DATE:
Method of Payment:
❑ Cash 0 Check 0 Visa 0 MasterCard 0 Discover Card
Date: Expires:
Bankcard Number:
Authorized Signature:
Spokane County Division of Building&Planning
1026\Vest Broadway Avenue '`Spokane WA 99260
Tel. No. (509) 456-3675 Fax No. (509) 456-4703 TDD No. (509) 324-3166
PLUMBING PERMIT APPLICATION
PROJECT PERMIT
ADDRESS: USE:
OWNER: PHONE:DAYTIME CONTACT
MAILING ADDRESS:
(street) (city/state) (zip)
CONTRACTOR: p,R..z.4„,f(,1 pLafyLbk.f)_(r LICENSE: 8 E61- Ai-P *- cb -3f;5 Mr
PHONE: q,2--2- - )5 -F/
MAILING ADDRESS: E. 18 i-ut(e Ai 1/.._; 0 cer) ciCre_S oIA- 9 q >i G
(street) (city/state) (zip)
PLUMBING FIXTURES #OF MULTI. COST
DESCRIPTION I DETAIL UNITS MED BY /UNIT EQUALS AMOUNT
B02: TOILETS WATER CLOSETS,BIDETS x S6 = $
B63: URINALS - x S6 = $
k4: TUBS BATH,JACUZZI,SPA,GARDEN x S6 = $
....
B65: SHOWERS(per trap) BASE,STALL,ON-SITE BUILD X 56 = $
:I* SINKS LAVS/BASINS,BAR,FLOOR,KITCHEN, X S6 = S
LAUNDRY,UTILITY,JANITOR,PHOTO,
X-RAY,FOOD(PREP/CULINARY/MEAT)
B07: DISHWASHER - x 56 _ = S
:B08 CLOTHES WASHER - x S6 = S
:l60. GARBAGE DISPOSAL/GRINDER - x
MO: WATER SOFTENER
-
x S6 = $
56 = $
:B1:1: ELECTRIC HOT WATER TANKS (NOTE: if gas water tank,see mechanical) _ X $6 = $
:B12: FLOOR DRAINS AREA,CASE,COIL,TRENCH,CONDENSATE x S6 = $
B1.3i ROOF DRAINS/OVERFLOW DRAINS(ea. - x $6 = $
B14::FOUNTAINS,DRINKING - x $6 = $
B15::W 4 0 I,PIP!k _ II t. ' I -WASTE-VENT/ INSTALLATION,ALTERATION,REPAIR, x $6 = $
.-:•:::::::PLUMBING REVE' • III. . REVERSALS
:4.4 -. •
Blfi::SEWAGE EJECTORS GRINDER,SUMP PUMP x $6 = $
IB 7:;:WATER USING DEVICES ICE AND/OR COFFEE MAKER, X $6 = $
:•:•:•:•:: HOSE BIB,STEAMER,PROOFER,
CARBONATOR,SWAMP COOLERS
BM:CROSS-CONNECTION DEVICES VACUUM BREAKER,CHECK VALVE, X $6 = $
AND R.P.B.P.D.FOR:VATS,SUMPS,
TANKS,BOILERS,&SPRINKLER SYSTEMS
.—..
'B19.::INTERCEPTORS GREASE TRAP,SAND TRAP, x $6 = $
::::-:•::: CHEMICAL HOLDING TANK
B20::MEDICAL GAS(per outlet/bottle station) NITROUS,OXYGEN X $6 = $
B21::MISCELLANEOUS FIXTURES x $6 = $
Method of Payment: Subtotal
1 PLUS: PROCESSING FEE $25.00
I I
I I El ......145An
0 Cash Check % I-1 14111116-1.- 4;‘,''' DISCOVER TOTAL PERMIT FEE DUE $
.. .. . . .
FAXED PERMITS WILL ONLY BF ACCEPTED WITH PAYMENT OF A MAJOR CREDIT GIRD :•:.:.:.::.:.:-:.:-:.:::::"::::: : .::: :::.. .. ::.:. : ::
:.:.:.:MINIIVI Wf,PUMIT fa.1.51-$-342P:::
Date: Expires: ::: :i:::::::4EA$lg:is;f*k.0-4E(0:PAYOtkid::h:::::::::
Bankcard Number: ::::::::::::•:•:.:.:::::.::•:.:•:•:::-:.:-:.:.•••••••...i. -.:•...::•.•:•.••• .........:•:•:•:::•:•
Authorized Signature: i: ::::::::::::::::: :::::::::::::::::: :::::::::::H.:::.:: ::::::::::
12/1 9/97 master\plumbperrn.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
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