2008, 06-17 Permit App 08002306 Cross Connection e •'►
�0"\,. Permit Center
SO—Acme 11703 E Sprague Ave,Suite B-3 PERMIT NUMBERP, .Sofa
Spokane Valley,WA 99206
(509)688-0036 FAX:(509)688-0037 PERMIT FEE: !
Community Development www.spokanevalley.org
Plumbing Permit Application n Commercial Residential
SITE ADDRESS: _ 013 Iv., Co LE'AN/4 12 p 9 5 PD 1 AJ i-L- w A 'l 2I Z.
Building Owner (W) , !35_4 g(,t I
Name: AA i V E R A C u 5 Phon`e( ) 54 0 -ti 2 S 3 Fax:
Address: 3 0 )3 ,JJ C 0 L E AA.A/J RD , City: S po K, V ALL E(/ State: IN R Zip: q g 2 I Z
Contractor
Name: $$A As 60J%E 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 r 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 ❑CHECK ❑VISA ❑MC EXPIRES: $35.00
Card# VIN: j TOTAL PERMIT FEE DUE:
AUTHORIZED SIGNATURE: NV�µJ ��r�✓
Effective October 28,2007
P:\Community Development\Forms\Building forms\Plumbing Permit Application.doc