1999, 09-16 Permit App: 99008749 Sewer?‘17
Spokane County Division of Utilities
SEWER 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.
Also note that sewer permits are valid for 12 months from the date of issuance. No extensions will be granted.
PROJECT INFORMATION
Job address:
/41/3 so I vpt •r+ � City: 4 per! tvp
Zip: 5; f
Parcel number(ifknown):
Dry Line
IN
Owner's name:
GUf 2 S Also c /Ale-
City/State: p B ?is. /Vci--t/ S-OGG�r.,•�.. -a
Zip: 991.//
Phone:
�LZ- o?4L --
First -time contractors or home - owners performing the installation must first contact the utili 'es department (in person or via phone
[456-3604]) before a permit can be issued.
Name of Utilities Division person contacted:
CONTRACTOR INFORMATION
Contractor (company name):
�F l// N * e All
Business address:
State contractor license number:
City /State:
Zip: Phone:
Contact Name:
Phone:
INTERIOR PLUMBING ALTERATIONS? (yes /no) circle one
Fill out the information in the table below if applicable **
Contractor (if different from above): Phone:
Business Address: City /State/Zip:
*4' For plumbing reversal fee information see reverse side: of this
FEE INFORMATION
Sewer Connection: Number of Buildings X (times) $100 (pet 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 single ownership, one permit is required
• Multiple buildings (apartments, industrial complexes) with single ownership, one permit required per building connecting to
the sewer.
(For situations not overed here, call the County Division of Utilities @ 456 -3604)
APPLICANT SIGNATURE:
Date: fAyii,
Return to:
Spokane County Division of Building & Planning
West 1 026 Broadway Avenue * Spokane, Washington 99260
PHONE: (509) 456 -3675 * FAX: (509) 324 -3198 * TDD: (509) 324 -3166
Spokane County does not disc n mate on the bans of dasabt6ty to the adnumon m, of treatment or employment sn, its programs or acvnoec
PLUMBING PERMIT APPLICATION
PROJECT ADDRESS:
OWNER:
PHONE: DAYTIME CONTACT
MAILING ADDRESS:
CONTRACTOR:
(street)
(city/state)
(Zip)
MAILING ADDRESS:
LICENSE:
PHONE:
(street)
(city/state)
PLUMBING FIXTURES
DESCRIPTION DETAIL
B02 TOILETS
WATER CLOSETS, BIDETS
# OF MULTI -
UNITS PLIED BY
COST
/UNIT EQUALS
(zip)
AMOUNT
x
$6
1303 URINALS
B04 TUBS
x
$6
BATH, JACUZZI, SPA, GARDEN
x
$6
B05 SHOWERS (per trap)
06
BASE, STALL, ON -SITE BUILD
x
SINKS
B07 DISHWASHER
LAVSBASINS, BAR, FLOOR, KITCHEN,
LAUNDRY, UTILITY, JANITOR, PHOTO,
X -RAY, FOOD (PREP /CULINARY/MEAT)
x
x
$6
$6
$6
B08 CLOTHES WASHER
x
$6
B09 :. GARBAGE DISPOSAL /GRINDER
BM. I WATER SOFTENER
x
$6
x
$6
B11 ELECTRIC HOT WATER TANKS
B1JFLOOR DRAINS
(NOTE: if gas water tank, see mechanical)
x
$6
MI: ROOF DRAINS /OVERFLOW DRAINS
j3j4;1FOUNTAINS, DRINKING
1315
AREA, CASE, COIL, TRENCH, CONDENSATE
x
$6
x
$6
x
$6
WATER PIPING/DRAIN- WASTE -VEN
PLUMBING REVERSALS
316 SEWAGE EJECTORS
331`7.!
INSTALLATION, ALTERATION, REPAIR,
REVERSALS
x
$6
GRINDER, SUMP PUMP
x
WATER USING DEVICES
CROSS - CONNECTION DEVICES
B19.. INTERCEPTORS
ICE AND /OR COFFEE MAKER,
HOSE BIB, STEAMER, PROOFER,
CARBONATOR,SWAMP COOLERS
320 IMEDICAL GAS (per outlet/bottle station)
'1321 MISCELLANEOUS FIXTURES
VACUUM BREAKER, CHECK VALVE,
AND R.P.B.P.D. FOR: VATS, SUMPS,
TANKS, BOILERS, & SPRINKLER SYSTEMS
x
$6
$6
GREASE TRAP, SAND TRAP,
CHEMICAL HOLDING TANK
NITROUS, OXYGEN
x
$6
x
$6
$
x
$6
x
$6
NOTE: MINIMUM PERMIT FEE IS $35.00
❑ RESIDENTIAL ❑ COMMERCIAL
SIGNATURE:
Spokane County Division of Building & Planning
1026 W. Broadway Avenue * Spokane, \VA 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.
1 WI 4,'M \.nasscrylumperm hnd
Subtotal
PLUS: PROCESSING FEE
$25.00
TOTAL PERMIT FEE DUE
&SE.IVIAKE CI ELKS PAYABLE T
E. COUNTY :TER CBNTE:
•
U r.LrrES CtvISICN
N. 5r -ice 3jWls• P.E.. Utilities Director
9 / /97
A Dr/ ON CF TI-SE PUSC:C WcR:cs DE.'.+RTnE -
GENERAL FACILITIES CHARGE (GFC)
PAYMENT OPTION SELECTION RECORD
Nc(s)
Site •;Cressi35): 1713 So 4v'fl'n
�er
Name: GO. ,' S se' Gt414- -e- OR Owner Name:
_s Cct :cn (Check Ore):
Gam.,. payment received at issuance cf Sewer Cz.,nnecticn Fermit by
0. ) �O b � P a , a� c\ 0 5 t n Cwisicr
■
Ca'/rr ent in 24 e''ual mcr,thly cayments uccn estaciishment cf Sewer c;i irc Account.
Complete one cf the foilcwing statements.
Cw^er's Statement: I. al. $ �! ASSoc. ,t.' C.. t-at I 'Neil
Ilie fcr the applicable GEC amcur.t In 24 monthly Instailments T rncrtniy G^C
Instai!ments will be acdec tc my monthly sever service charges.
i:%;::?1•6(e4.10'CX,
r -,ICer s Sia: r er:t: I.
teca,._se I ahh, select ; ^C this cc ::cn for payment cf the GFC. that t%e _ .. e hcr7.,e
=sccrs :ble for payment Cr acoiicabl_ G-':. in 2= eyt:aI rrc' :. %
— isc cs ib 'Cter t:al : -.e :rccerty tra: the Grp. -ha,-des 'Pii,. _= a___ tio :-e
bIllincs as s:cr as Pilling ccn n er:ts.
c;:leers " rr_e r :e cresentaii'ie's Signa:.'re Date
Spck3r,e Ccunr/,
Oivisicrr cf Utilities
=� Einadwa., • 5pckar,,e. wA 99: )-O (l • (5C9) 477-3604 FAX: (509) 477471.5 T00: (51:x) 3_; -3lio
GFC P3yr'7?r: Qp :!c 1 Form
revised 1/26'99