2008, 08-01 Permit App: 08002986 Cross Connect Permit Center
k e 11703 E Sprague Ave,Suite B-3 t' L
j cr—/s Spokane Valley,WA 99206 PERMIT NUMBER: ! ,D
(509)688-0036 FAX:(509)688-0037 PERMIT FEE:
Community Development perrnitcenter(aspokanevalley.org
Plumbing Permit Application n Commercial n Residential
SITE ADDRESS: I I IE . 35mow¢, SOo�CdK 1/q , WA- 6192.6
Building Owner
Name: {./„ i !� f J Son Phone: /I e2$ 34620 Fax:
Address: nI��a� G -NwTC moi Ave_ CitY:N Kd-N.I �iet I State: �� Zip: n174)
Contractor
Name: Phone: Fax:
Address: City: State: Zip:
License No: City Business Lic:
Contact
Name: Phone:
DESCRIPTION OF WORK #OF UNITS X COST = TOTAL AMOUNT
1 TOILETS WATER CLOSET,BIDETS X $6.00 =
2 URINALS X $6.00 =
3 TUBS X $6.00 =
4 SHOWERS(PER TRAP) BATH,STALL,ON-SITE BUILT X $6.00 =
LAYS/BASINS,BAR,FLOOR,KITCHEN,
5 SINKS LAUNDRY,UTILITY,JANITOR,PHOTO, X $6.00 =
X-RAY,FOOD,PREP/CULINARY MEAT
6 DISHWASHER X $6.00 =
7 CLOTHES WASHER X $6.00 =
8 GARBAGE DISPOSAL X $6.00 =
9 WATER SOFTENER X $6.00 =
10 ELECTRIC WATER HEATER NOTE: IF GAS,SEE MECHANICAL X $6.00 =
AREA,CASE,COIL,TRENCH,
11 FLOOR DRAINS CONDENSATE X $6.00 =
12 ROOF DRAINS/OVERFLOW DRAINS X $6.00 =
13 FOUNTAINS,DRINKING X $6.00 =
WATER PIPING/DRAIN-IN WASTE, NSTALLATION,ALTERATION,REPAIR,
14 VENT,PLUMBING,REVERSAL REVERSALS X $6.00 =
15 SEWAGE EJECTOR GRINDER,SUMP PUMP X $6.00 =
ICE AN/OR COFFEE MAKER,HOSE BIB,
16 WATER USING DEVICE STEAMER X $6.00 =
PROOFER,CARBONATOR,SWAMP
COOLER
VACUUM BREAKER,CHECK VALVE,
AND R.P.B.P.D.FOR: VATS,TANKS,
17 CROSS CONNECTION DEVICE BOILERS X $6.00 = �-
GREASE TRAP,SAND TRAP,
18 INTERCEPTORS CHEMICAL HOLDING TANK X $6.00 =
19 MEDICAL GAS(per outlet) NITROUS,OXYGEN X $6.00 =
20 MISCELLANEOUS PLUMBING FIXTURE X $6.00
21 PRIVATE SEWAGE DISPOSAUSYS X $20.00 =
22 INDUSTRIAL WASTE INTERCEPTOR X $15.00 =
SUBTOTAL
METHOD OF PAYMENT:
PROCESSING FEE
❑CASH 0 CHECK 0 VISA 0 MC EXPIRES: $35.00
Card# VIN: TOTAL PERMIT FEE DUE:
AUTHORIZED SIGNATURE:
REVISED 8/26/05