2007, 05-09 Permit App: 07002843 SewerScokane 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. 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
_lob Address: I I L( N.. CA fi If -,(.3
Parcel Number. 3 1 3(, o `i1 o (`'
Project Name:
MID Name:
I sot:
Block:
CHECK APPLICABLE BOXES
O Regular
O Dry Sewer
O Repair
O Addition
O Abandonment
O Residential
O Commercial
D Temporary
O New
O New
Owner's name: (C;
;lddress:
City/State:
Zip:
Phone:
1 IL( t1. L( Li
* FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMING THE INSTALLATION MUST FIRST CONTACT THE
UTILITIES DIVISION BEFORE PERMITS) CAN BE ISSUED.
SIGNATURE OF UTILITIES DIVISION PERSON CONTACTED:
Contra or (company name):
Sate contractor license number.
Business address: r f �n t•
City/State: (// Zip: 5'1 / 1'
Contact Name:
,+, r/e
� yc
Phone Number. `? -- (/ - S-Z/t1
INTERIOR PLUMBING ALTERATIONS?
Fill met the information in the table below if applicable
/no) circle one
0 County City of Spokane Valley
Contractor (if different from above): Phone:
Business Address:
City/State/Zip
**For;Spokane County pinnbint reversalfet in. foinfOoar; .ret merr;ndc eibidoiiik
FEE INFORMATION
Number of Buildings connecting to sewer X (times) 5100 (per bldg) = S+ $10.00 = SPOKANE COUNTY
RIGHT 01' WAY PERMIT
• Fora single-family residential unit, one pemnt is required;
• For a condominium, townhouse, duplex, tripler 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 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? D Yeso
0 C unty D City of Spokane Valley
IPPLICANT SIGNATURE:
1
Owner or ntractor
cle one)
DATE: _ - f ) 7
iethod of Payment:
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 AvenueSpokane WA 99260
Tel. No. (5I)9) 477-3675 * Fax No. (509) 477-7198' TDD No. (509) 477-7133