2007, 06-29 Permit App: 07004283 SewerSpokane County Division of Utilities
SEWER CONNECTIONPERAIIT 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. Sewer permits are valid for 12
months form the date of issuance. A separate right-of-way permit is required for any work performed in or from the public right-of-way. All interior
plumbing and electrical work requires separate permits.
PROJECT INFORMATION
Job Address
Parcel Number.
Project Name:
ULID Name:
Lot Block:
CHECK APPLICABLE BOXES
Regular
❑ Dry Sewer
❑ Repair
❑ Addition
❑ Abandonment
R. Residential
Commercial
Temporary
O New
• New
0 - L(2,C3
Owner's name: )-7 ' . w / Z—s U`
Address: Li / S^ CL' S /L
City/State: SIB ( 2 l e/
Zip: l F z/ Z
Phone: SD �C / 6o4,4
* FIRST TIME CONTRACTORS OR HOME OWNERS PERFOR1117)
THE INSTALLATIUST FIRST CONTACT THE
UTILITIES DIVISION BEFORE PERMIT(S) CAN BE ISSUED.
SIGNATURE OF UTILITIES DIVISION PERSON CONTACTED:
Contractor (company name):
Sate contractor license number.
Business address:
City/State: Zip:
Contact Name:
Phone Number:
INTERIOR PLUMBING ALTERATIONS? (yes/no) circle one
Fill out the information in Ibe table below rf applicable"
U County 0 City of Spokane Valley
Contractor (if different from above): Phone:
Business Address: City/State/Zip
"For Spo Ea rCo r i i pllnrbifeA withal:1 i0 atiog at mans
FEE INFORMATION
Number of Buildings connecting to sewer X (times) $100 (per bldg) = $ + $10.00 = SPOKANE COUNTY
RIGHT OF WAY PERMIT
• Fora single-family residential unit, one permit is required;
• Fora condominium, townhouse, duplex, triplex or fourplex with separate ownership (u 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 budding connecting to the sewer.
(FOR SITUATIONS NOT COVERED HERE, CALL THE COUNTY DIVISION OF UTILITIES AT 477-3604)
Is any of the work to be performed in or from the public right-of-way? CI Yes D No
oun;ty ,123 City of Spokane Valley
APPLICANT SIGNATURE: 4(J1C2i (1 7 �/ �� U�✓� DA I
Contractor (circle one)
Method of Payment:
0 Cash 0 Check 0 Visa 0 MasterCard 0 Discover Card
Date: Expires:
Bankcard Number:
Authorized Signature:
Spokane County Department of Building and Planning
1026 West Broadway Avenue Spokane WA 99260
Tel. No. (509) 477-3675 " Fax No. (509) 477-7198 * TDD No. (509) 477-7133