2007, 09-24 Permit App: 07006558 Sewerr
Spokane 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
Job Address: VO4O E•^i >< ILi 11^ AVG
Parcel Number:4613 4 3
. 1 { .._Lee —NOM
Project Name: W LI AG. at re
LTUZQa' Sr
Af Regular
❑ Dry Sewer
❑ Repair
❑ Addition
❑ Abandonment
CHECK APPLICABLE BOXES
Al Residential
O Commercial
O Temporary
13 New
0 New
Owner's name: LI ct Y t -1e e tv4A
a
Address: /L/ 2 f 3'✓/L"1"" 3119
�J
City/State: S 72e9G
Zip: 77.2e9
Phone50 / / 2
* FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMING THE INSTALLATION MUST FIRST CONTACT THE
UTILITIES DIVISION BEFORE PERMIT(S) CAN BE ISSUED. sa t b s u $. V tft rn t vv
SIGNATURE OF UTILITIES DIVISION PERSON CONTACTED: (7 45 PEG TO R) '`< , V'✓• >�
Contractor m ny name):nt�N
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 the table below if applicable**
❑ County 0 City of Spokane Valley
Contractor (if different from above): Phone:
Business Address:
City/State/Zip
FEE INFORMATION 1 V
Number of Buildings connecting to sewer 1 X (times) $100 (per bldg) = I�0 + ,$1915-= SPOKANE COUNTY
RIGHT OF WAY PERMIT
• For a single-family residential unit, one permit is required;
• For a condominium, townhouse, duplex, triplex 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? O Yes Ai No
County City of Spokane Valley
APPLICANT SIGNATURE:
DATE: Y- °7
Owner or 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