Loading...
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