2007, 05-22 Permit App: 07003169 SewerSpokane 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 rlectrical work requires separate permits.
PROJECT INFORMATION
cl -369
Job Address: 37-_0 G% /,/,,,Rd
Parcel Number. i.v ) e /6z)/ Lot: Block:
Project Name:
Ell .11) Name:
CHECK APPLICABLE BOXES
l7 Regular iesidential 0 New
O Dry Sewer 0 Commercial 0 New
O Repair 0 Temporary
O Addition
O Abandonment
Owner's name:
Address:
City/State:
Zip:
Phone:
/94u/ YjCo,i44
302-0 f-1 /, /I/ # /
(
*
* FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMING THE INSTALLATION MUST FIRST CONTACT THE
UTILITIES DIVISION BEFORE PERMIT(S) CAN BE ISSUED. %",
SIGNATURE OF UTJLITIES DIVISION PERSON CONTACTED: ( -E• Lit 4)
Contractor (company name):
ftmir
Business address: lgvi) .5 11Vlfl,
Sate contractor license number.
City/State: &A- L`1%474c6 t/-('- Zip: II" 6
Contact Name:
Phone Number.
44 vze,) L)
INTERIOR PLUMBING ALTERATIONS? (yes no� circle one
Fill out the information in the table below if opphcable**
0 County 0 City of Spokane Valley
Contractor (if different from above): Phone:
Business Address: City/State/Zip
**For Spokane County p/unsbin rrcrrral fre in. jormalion, sn meas; i S fibir fomtr
Number of Buildings connecting to sewer
FEE INFORMATION
X (times) 5100 (per bldg) = S + $10.00 = SPOKANE COUNTY
RIGHT OP WAY PERMIT
For a single-fanuly residential unit, one permit is required;
For a condominium, townhouse, duplex, triplex or fourples with separate ownership (as determined by lot lines) separate address and separate stub, one permit is required per address per stub;
For a single Wading duplex, tripks or fourpks with single ownership, one permit is required
Multiple buildings (apartments, industrial compkses) 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)
[s any of the work to be performed in or from the public right-of-way? , Yes 0 No
0 County 0 City of Spokane Valley
PPLICANT SIGNATURE:
Owner or Contractor (circle one)
DATE: 54-- 2-cp.0
Method of Payment:
Cash
D Check 0 Visa
Date:
D MasterCard 0 Discover Card
Expires:
Bankcard Number:
Authorized Signature:
Spokane County Department of Budding and Planning
1026 West Broadway ;Avenue'r Spokane WA 99260
Td. No. (509) 477-3675Fax No. (509) 477-7198 TDD No. (509) 477-7133