2006, 05-11 Permit App: 06002962• 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. al interior
plumbing and electrical work requires separate permits.
PROJECT INFORMATION
Job Address: 1 - Li /V /U(4 r 4,r/7 (ie.
Parcel Number I l 0 �(� t7 `7 Lot. Block:
Project Name: f f c i r' t 4fz' . J c' w t v
ULID Name:
CHECK APPLICABLE BOXES
Regular
❑ Dry Sewer
❑ Repair
❑ Addition
❑ Abandonment
O Residential
O Commercial
O Temporary
0 New
O New
Owner's name: Jt/(t L �1
Address: -2 5 : 1'
l�
GLzrI `Gist
/(%
City/State:
Zip: CI Z/ Z
Phone: /0 -�
j',7 5
�- 13
* 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):(4_.
6L -
Sate contractor license number.
Business address:
City/State: V 5r
Zip:
Contact Name:
Phone Number:
INTERIOR PLUMBING ALTERATIONS? (yes no circle one
Fill out the information in the table below if applicable*
❑ County ❑ City of Spokane Valley
Contractor (if different from above):
Business Address:
Phone:
City/State/Zip
FEE INFORMATION
Number of Buildings connecting to sewer X (times) $100 (per bldg) = $ + $10.00 = 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 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? O Yes CI No
0 County ❑ City of Spokane Valley
APPLICANT SIGNATURE:
Owner or Contractor (circle one)
DATE:
Method of Payment:
CI 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
PLUMBING PERMIT APPLICATION
PROJECT
ADDRESS:
PERMIT
USE:
OWNER:
PHONE (Daytime Contact):
MAILING ADDRESS:
(Street) (City/State) (Zip)
CONTRACTOR:
LICENSE:
MAILING ADDRESS:
PHONE:
(treet) (Citi/StateL (Zip��
PLUMBING FIXTURES
DESCRIPTION
DETAIL
# OF
UNIT
S
Much
PLED
BY
COST/
UNIT
EQUALS
AMOUNT
TOILETS
WATER CLOSETS, BIDETS
x
$6
=
URINALS
-
x
$6
=
TUBS
-
x
$6
=
SHOWERS (per trap)
BATH, STALL, ON-SITE BUILD
x
$6
=
SINKS
LAVS/BASINS, BAR, FLOOR, KITCHEN,
LAUNDRY, UTILITY, JANITOR, PHOTO, X-
RAY, FOOD (PREP/CULINARY/MEAT
x
$6
=
DISHWASHER
-
x
$6
=
CLOTHES WASHER
- .
x
$6
=
GARBAGE DISPOSAUGRINDER
-
x
$6
=
WATER SOFTENER
-
x
$6
=
ELECTRIC HOT WATER TANKS
(NOTE: if gas water tank see mechanical)
x
$6
=
FLOOR DRAINS
AREA, CASE, COIL, TRENCH,
CONDENSATE
x
$6
=
ROOF DRAINS/OVERFLOW DRAINS (ea.)
-
x
$6
=
FOUNTAINS. DRINKING
-
x
$6
=
WATER PIPING/DRAIN-IN WASTE-
VENT/PLUMBING REVERSALS
INSTALLATION, ALTERATION, REPAIR,
REVERSALS
x
$6
=
SEWAGE EJECTORS
GRINDER, SUMP PUMP
x
$6
=
WATER USING DEVICES
ICE AND/OR COFFEE MAKER, HOSE BIB,
STEAMER, PROOFER, CARBONATOR,
SWAMP COOLERS
x
$6
=
CROSS CONNECTION DEVICES
VACUUM BREAKER, CHECK VALVE, AND
R.P.B.P.D. FOR : VATS, SUMPS, TANKS.
BOILERS, & SPRINKLER SYSTEMS
X
$6
=
INTERCEPTORS
GREASE TRAP, SAND TRAP, CHEMICAL
HOLDING TANK
x
$6
-
MEDICAL GAS (per outlet/bottle station)
NITROUS, OXYGEN
x
$6
=
MISCELLANEOUS FIXTURES
-
X
$6
=
METHOD OF PAYMENT
0 DISCOVER
PAYMENT OF A MAJOR CREDIT CARD
SUBTOTAL
PLUS: NON-REFUNDABLE
PROCESSING FEE
$ 25.00
NI CASH 0 CHECK 0 VISA 0 MASTERCARD
FAXED PERMITS WILL ONLY BE ACCEPTED WITH
DATE: EXPIRES:
SUBTOTAL: MINIMUM PERMIT
FEE IS $35.00
PLUS: 16% REGIONAL PLANNING
SURCHARGE
BANKCARD NUMBER:
TOTAL PERMIT FEE DUE
AUTHORIZED SIGNATURE:
Spokane County Department of Building and Planning
1026 West Broadway Avenue' Spokane, WA 99260-0050
Telephone No. (509) 477-3675 • Fax No. 477-7198 * TDD No. (509) 477-7133