2006, 08-07 Permit App: 06005468 Sewer• Spokane County Division ofUtilities
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. 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: 70S-- Y\
Parcel Number: `7'56'./. `= / Kbit: Block:
Project Name:
UI,ID Name:
CHECK APPLICABLE BOXES
❑ Regular
❑ Dry Sewer
O Repair
❑ Addition
O Abandonment
Ar. ---Residential D New
Commercial D New
D Temporary
City/State:
Zip -
Phone: 4t�" --7-ce, 3 -7
* 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 (company name
Sate contractor license number:
Business address: ? 0-7
City/Statc:7 f //L� Vote' zip: ,D,_2"3
Contact Name:
Phone Number:
INTERIOR PLUMBING ALTERATIONS? (yes/o) circle one
Fill out the information in the table below if applicable*
County ❑ City of Spokane Valley
Contractor (if different from above): -Phone:
Business Address:'
City/State/Zip
**For Spokane. Count' plumbing reversal fee information, see reverse side of lbrs form
FEE INFORMATION
Number of Buildings connecting to sewer X (times) S100 (per bldg) = 5 + $10.00 = SPOKANE couN'n'
RIGHT OF WAY PERMIT
• For a single-family residential unit, one permit is required;
• For a condominium, townhouse, duplex, triples or fourplcx with separate ownership (as determined be lot lines) separate address and separate stub, one permit is required per address per stub;
• For a single building'duplex, triplex or fourplex with single ownership, one permit is required -
• - Multiple buildings (apartments, industrial complexes) u-ith .single ownership, one permit required per building connecting to the sewer.
(FOR SITUATIONS NOT COVERED HERE, CALL THE COUNTY DIVISION OF UTILITIES AT 477-3604)
Is any of the work to be performed in or om the public right-of-way? D Yes
Coun ❑ City o Spokane Valley
APPLICANT SIGNATURE:
Method of Payme
0 Cash
Check.' 0 Visa 0 MasterCard 0 Discover Card
ate: Expires:
Bankcard Number: -
Authorized ,Signature:
No
DATE:
Spokane County Department of$uilding and Planning.
1026 \Vcst`Broadway avenue "''Spokane WA 99260
'Fd. No. (509) 477-3675' Fax No. (509) 477-7198. TDD NO. (509) 477-7133