1994, 11-15 Permit App: 94011456 Plumbing ReversalSEWER 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.
PROTECT INFORMATION
Job address:
Owner's name:
City:
City/State:
Zip:
Zip: Q �%/
Parcel number (if known):
Phone:
WILL THE PROPERTY OWNER BE PERFORMING THE SEWER CONNECTION
INSTALLATION?* _Yes _�==No
*If property owner is installing the sewer connection, they mi stfirst contact the UTILITIES DEPARTMEATfor con.snucdon
requirements before the permit is issued.
CONTRACTOR INFORMATION
Contractor (company name):
State contractor license number:
Business address:
Utilities installers permit number:
I '
City/State Sn (i U/
Zip: G 92.0 Phone: G 2f. - BG (_�z
INTERIOR PLUMBING ALTERATIONS (ifappucabie)•-
Contractor (if different from above): Phone:
Business Address: City/State/Zip:
** For plumbing reversal fee information, see reverse side of this form.
FEE INFORMATION
Sewer Connection: Number of Buildings X (time.) $50 (perbidg)
TOTAL FEE
(One permit required for cads separate baffding, shop, garage, etc., that will be connected to the sewer)
APPLICANT SIGNATURE: / Date
Spokane County Division of Buildings
West 1026 Broadway Avenue * Spokane, Washington 99260 * (509) 456-3675
PLUMBING PER1bIIT APPLICATION qJ
OWNER: PHONE:
MAILING ADDRESS:
(street) (city/state) (rip)
MAILING ADDRESS:
(street) (city/state) (rip)
,.,. no. t.rusJ. a -au re - rax No. (aur) oo-4/V3 • TUU No. (Juv)
P MBING I TURE
Des R N D1912,11.
OF
UNIT
r".
�x •Y
OST
NIT
.,,
AMOUNT
B02
TOIIEB
WATER ==& BIDETS
$6
-
$
BO.1
URINALS
x
$6
=
S
BO:
TUBS
BAMJACJ=LSPAGARDEN
x
$6
-
S
1305
SHOWERS er tra
BgsEsrwtL GN-STre eIIDD
x
$6
-
S
B06
SINKS
uv5/BASINRBM.FTDORKHY}QIN,
utINDRY. VIMY.JANrroRPNOTO.
X-RAY.FOOD REPCULINARY41
x
$6
=
S
B07
DISHWASHER
x
$6
=
S
BO
CLOTHESWASHER
x
$6
=
S
BO
GARBAGE DISPOSAUGRINDER
x
$6
=
S
BIO
WATER SOFTENER
x
$6
=
$
Bit
ELECTRIC HOT WATER TANKS
(NOT20p,.w.. net,,«=ch.eid)
x
$6
-
S
B12
FLOOR DRAINS
ARFn CASE,mB. TaeNa[CONOeNSAre
x
$6
=
S
Bl.
ROOF DRAINS/OVERFLOW DRAINS ea.
x
$6
=
$
B14
FOUNTAINS, DRINKING
x
$6
=
$
BIS
WATER PIPING/DRAIN-WASTE-VENT/
PLUMBING REVERSALS
BJSTADATION. ALTeMTION. RePML
ReveRSAt3
x
$6
=
$ t4
-
B16
SEWAGE EJECTORS
aRWpeR SUMeIVMe
x
$6
=
S
BI7
WATER USING DEVICES
ICeANDpR mFFEe MAKER
HOSE BIR SJ'PM6R PROOMP,
CARBONATGR SWAMP WOLER$
x
$6
=
S
B18
CROSS -CONNECTION DEVICES
vAC1BIM BReAKe0.Ctre(]r vALve,
ANDR.P.B.PD.FOR:VATSSII M
TA BOBERS.&SPRU LLERSYSTEMS
x
S6
=
$
B19
INTERCEPTORS
OREAte I'MP,sAND TRAP,
6B:MTCU.HOMMTANK
x
S6
=
$
B20
MEDICAL GAS r outlet/boulestation
NITROUS. OXYGEN
x
S6
-
$
B2I
MISCELLANEOUS FIXTURES I
x
S6
=
S
NOTE: AffMMUMPERMITFEEIS$35.00
SIGNATURE:
ipokane County Division of Buildings
1026 W. Broadway Avenue a Spokane, WA 99260
Subtotal
PLUS: PROCESSING FEE
$25.06
TOTAL PERMIT FEE DUE
S x"00
PLEASE MAKE CHECKS PAYABLE
SPOKANE COUNTY PERMIT
TO:
CENTER':
,.,. no. t.rusJ. a -au re - rax No. (aur) oo-4/V3 • TUU No. (Juv)