1996, 09-05 Permit App: 96007413 Sewer /-
SEWER CONNECTTION PERMIT
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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 that sewer permits are valid for 12 months from the date of issuance. No
extensions will be granted.
PROJECT INFORMATION
Job address: Dry Line Owner's name:
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City: I gf f City/State: stree.. ,.
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Zip: G ZLga 1 ```. ,/v p: Z-0 tri'
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Parcel number(ifknown): Q one: 4105 -D`t t S
First-time contractors or home-owners performing the installation must first contact the utilities department(in person
or via phone [456-3604]) before a permit can be issued. ,
Name of Utilities Division person contacted: 'lo.E K
CONTRACTOR INFORMATION
Contractor (company name): State contractor license number:
i r E>< GaVGL-hnJ ALLl _i lit L Z.
Business address: ✓ Utilities installers permit number:
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City/State: M ect cal L tAJ1A
Zip: q q o2-2. Phone: 2 q q - I I
INTERIOR PLUMBING ALTERATIONS? ( o) circle one
Fill out the information in the table below if applica e***
Contractor (if different from above): Phone: C 2 8 - 313 r7
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Business Address: City/State/Zip:
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**For plumbing reversal fee information,see reverse side of this form.
FEE INFORMATION cc�
Sewer Connection: Number of Buildings t X(times) $SO(per bldg) = $ Jk), `'`:1
TOTAL FEE
*One permit required for each separate building,shop,garage, etc., that will be connected to the sewer.
*Condos, townhouses, & 2-3-and 4-plexes require 1 permit per address/stub.
*Multiple buildings(apartments, industrial complexes) require 1 permit per building.
(For situations not covered here, call the County Utilities Division @456-3604)
APPLICANT SIGNATURE: Date: (/ =t
Spokane County Division of Buildings
West 1026 Broadway Avenue * Spokane, Washington 99260
PHONE: (509) 456-3675 * FAX: (509) 324-3198 * TDD: (509) 324-3166
Spokane County does not discriminate on the basis of disability in the admission to, or treatment or employment in,its programs or activities.
1/25/95c\,.,o. . .'pi
PLUMBING PERMIT APPLICATION
PROJECT ADDRESS: i 2 f z...-1 C 9 is
OWNER: 5"),1/4/4.4 Sc.--.4.--4._ PHONE:DAYTIME CONTACT L}- _ov 73
MAILING ADDRESS: 1 Zi lit L- "C , ,,,c,•Qeze,�� ` L. _ 91-7.:>G•
`/ (street) (city/state) (yip)
CONTRACTOR: CQr _rip em Pis LICENSE: e M re,-* 0/01 LO
PHONE: 92.8 •,..313r7
MAILING ADDRESS: I (4.7.5 o cps E, Lc o ci{em ow alne WA- 9c/2/L.
(street) city/state) (zip)
PLUMBING FIXTURES #OF mum- COST
DESCRIPTION I DETAIL UNITS MED BY /UNIT mQunt.s AMOUNT
B02 TOILETS WATER CLOSETS.BIDETS X $6 = $
B03 URINALS - x $6 = $
B04 TUBS BATH,JACUZZI,SPA,GARDEN x $6 = $
1305 SHOWERS(per trap) BASE,STALL,ON—SITE BUI D X $6 = $
1306 SINKS LAVS/BASINS,BAR,FLOOR,KITCHEN, X $6 = $
LAUNDRY,UTILITY,JANITOR,PHOTO,
X—RAY,FOOD(PREP/CULINARY/MEAT)
1307 DISHWASHER - x $6 = $
1308 CLOTHES WASHER - x $6 = $
B09 GARBAGE DISPOSAUGRINDER - x $6 = $
810 WATER SOFTENER - x $6 = $
B11 ELECTRIC HOT WATER TANKS (NOTE if gas water tank see mechanical) x $6 = $
1312 FLOOR DRAINS AREA,CASE,COIL.TRENCH,CONDENSATE X $6 = $
B13 ROOF DRAINS/OVERFLOW DRAINS(ea.) - x $6 = $
B14 FOUNTAINS,DRINKING - x $6 = $
1315 WATER PIPING/DR IN-WASTE-VENT/ INSTALtATIOK ALTERATION,REPAIR, x $6 = $
PLUMBINLEVERSAM2, REVERSALS 6 ..0
BI6 SEWAGE EJECTORS GRINDER SUMP PUMP x $6 = $
1317 WATER USING DEVICES ICE AND/OR COFFEE MAKER, X $6 = $
HOSE BIB,STEAMER,PROOFER,
CARBONATOR.SWAMP COOLERS
B18 CROSS-CONNECTION DEVICES VACUUM BREAKER,CHECK VALVE, x $6 = $
AND R.P.B.PD.FOR:VATS,SUMPS,
TANKS,BOILERS,&SPRINKLER SYSTEMS
B19 INTERCEPTORS GREASE TRAP,SAND TRAP, X $6 = $
CHEMICAL HOLDING TANK
1320 MEDICAL GAS(per outlet/bottle station) NITROUS,OXYGEN X $6 = $
B21 MISCELLANEOUS FIXTURES x $6 = $
NOTE: MINIMUM PERMIT FEE IS$35.00 Subtotal 6 a'0
PLUS: PROCESSING FEE $25.00
SIGNATURE: & , Ah-s.,c TOTAL PERMIT FEE DUE $ 3 W
90.4,,,c,O,
PLEASE MAKE CHECKS PAYABLE TO
Spokane County Division of Buildings SPOKANE COUNTY PERMIT CENTER
1026 W. Broadway Avenue *Spokane,WA 99260
Tel.No.(509)456-3675 • Fax No. (509)324-3198 •TDD No. (509)324-3166
Spokane County does not discriminate on the basis of disability in the admission to,or treatment or employment in,its programs or activities.
TRANS ai*Apk.O„a►d