2007, 09-24 Permit App: 07006549 SewerSpokane County Division of Utilities n y- Gs -c-1/
SEWER CONNECTION PERMIT APPLICATION FORM J
PLEASE NO'l E: 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 regp'ired IZr,any work performed in or from the public right-of-way. allinterior
plumbing and electrical work requires separate permits.
PROJECT INFORMATION
Job Address cR470—S— /(/ ,K ,1J j• /IC
Parcel Number.
Project Name:
ULID Name:
Lot: Block.
CHECK APPLICABLE BOXES
Regular
❑ Dry Sewer
❑ Repair
O Addition
❑ Abandonment
p- Residential
O Commercial
O Temporary
O New
O New
Owner's name.
Wdress:
City/State:
Phunc: ! < 5
S.srn1-e
t.cuser2
* FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMING THE INSTALLATION MUST FIRST CONTACT THE
UTILITIES DIVISION BEFORE PERMIT(S) CAN BE ISSUED.
SIGNATURE OF UTILITIES DIVISION PERSON CONTACTED -
Contractor (com�, an�nmtnc). 71, ` ac lei t
Sate contractor license number.
Business address:
City/State: Zip:
Contact Name:
Phone Number
INTERIOR PLUMBING ALTERATIONS? (yes/circle one
FS out the information in the table below if appBcable**'' \\
O County 0 City of Spokane Valley
Contractor (if different from above): Phone:
Business Address: City/State/Zip
**For Spokane County phembing reversalfte information, sett mein sick eftbis foi/is: '
FEE INFORMATION
Number of Buildings connecting to sewer / X (times) 5100 (per bldg) = S /epQ + :10.00 =te,474:1.
• For a single -Fundy residential unit, one permit is required;
• For a condominium, townhouse, duplex, triplex or ((surplus with separate ownership (as determined by for lines) separate address and separate stub, one permit s required per address per stub;
• Fora single budding duplex, niplex or (ourplex with single ownership, one permit is required
• Multiple buildings (apartments, industrial compkses) with sine ownership, one permit required per bolding connecting to the sewer
(FOR SITUATIONS NOT COVERED HERE, CALL THE COUNTY DIVISION OF UTILITIES AT 477-3604)
SPOKANE couwry
RIGHT OF WAY PERMIT
Is any of the work to be performed in or from the public right-of-way? O Yes
O` County 0 City of Spokane Valley
APPLICANT SIGNATURE: /c ,
Owner or Contractor (circle one)
'Method of Payment:
0 Cash 0 Check O Visa 0 MasterCard 0 Discover Card
Date: Expires:
Bankcard Number:
Authorized Signature:
Spokane County Department of Building and Planning
1(126 Wot Broadway Avenue * Spokane WA 99260
'It l No (509) 4773675 • Fax No (509) 477-7198 ' TD1) No. (509) 477-7133