2007, 06-07 Permit App: 07003642 SewerSpokane County Division of Utilities
SEWER CONNECTION PERMIT APPLICATION FORM
PLEASF: NOTI-: This application form must Ix- 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 intenor
plumbing and electrical work requires separate permits.
Job Address: 2a24- N r/ lain i .
Parcel Number:
Project Name:
1.11,11) Name -
45221. Wif Lnr
►,\olcx
PROJECT INFORMATION
Block:
CHECK APPLICABLE BOXES
pRegular
❑ Day Sewer
- ❑ Repair
O Addition
O Abandonment
O Residential
O Commercial
O Temporary
C}I New
0 New
Owners name Lien len / ✓la iter
Address: 134 K Yl'/a414-21Y
City/State:
/..p:
9927
Phone: `S-61 aZ16
* 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 C.ONTACIP.D.
Contractor (company na c)
Sate co�ntractor.license number
ge-Ca.ti.Q /20 OR
Business address:
n
City/Statal-/,./.0 4JA Zip: 996x7
Contact Name
l Dr /Teem
Phone Number/S-1 c 9,39-01 3 8 9S 1--xrrx3C
1
INTERIOR PLUMBING ALTERATIONS? (yes(
Fi//out the iI formation In the table below rf applicable**
circle one
0 Counry 0 City of Spokane Valley
Contractor (if different from above): Phone:
Business Address:
City/State/Zip
**For Spokane Comb plumbing rrwrsal fee information, see reverie side ofIbis foini:4*'
Number of Buildings connecting to sewer
FEE INFORMATION
/) X (times) S100 (per bldg,) = S + $ 10.00 =
SPOKANE COoYn.
RIGHTOr WA\ FERAIIT
• for a single, family residential unit, one pent is required;
• For a condominium, townhouse, duplex, Mplex or fourplex with separate owmenhip (as determined by lot Tines) separate address and separate smb, one permit is required per address per smb;
• For a single budding duplex, triples or fourplex with single ownership, one permit is required
• Multiple buildings (aparunenn, nduvnal complc.es) n,th angle ownership, one permit required per budding 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? R' Yes 0 No
0County 0 City of Spokane Valley
APPLICANT SIGNATURE: / &ma DATE: — 7- -.7 no -7
Owner orContract rjcircle one)
"Method of Payment:
0 Cash El Check 0 Visa 0 MasterCard 0 Discover Card
Date: Ezpires-
Bankcard Number:
Authonzed Signature:
Spokane County Department of Budding and Planning
1026 \X est Broadway As cnuc' Spokane WA 99260
'IU No (509) 477-3675 Fax No. (509) 477-7198 • TDD Na (509) 477-7133