2006, 06-28 Permit App: 06004392 SewerSpokane County Division of Utilities
V (� 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: l,3/ i1 0,11 1 4- ikt Ptt
Parcel Number. ! Lot Block:
Project Name: , /l • ��
ULID Name: ` f' (
CHECK APPLICABLE BOXES
®regular
❑ Dry Sewer
O Repair
O Addition
O Abandonment
rE1,-Residential O New
O Commercial O New
O Temporary
Owner's name: 1` 06 & f- C' /moi /l
Address: / 3i R 5 .14 -ii 7:r/ .� h DIC
City/State: S /i ✓1
Zip: �ifCi2/�
Phone:
* 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):
Sate contractor license number.
Business address: :.L•rl �' �rzss /0 i)
City/State: 6116t61:- J4c, i7 i-5 LA'. 4 Zip:'E D/(,
Contact Name:
/iF C7+r.2,,4'rc
Phone Number. 2-5—/' g 8
INTERIOR PLUMBING ALTERATIONS? (yes no circle one
Fill out the information in the table below if applicable**
0 County 0 City of Spokane Valle;
Contractor (if different from above):
Business Address:
Phone:
City/State/Zip
Number of Buildings connecting to sewer
• For a single-family residential unit, one permit is required;
FEE INFORMATION
X (times) $100 (per bldg) = $
+ $10.00 = SPOKANE COUNT)
RIGHT OF WAY PERMIT
• 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 budding duplex, triplex or fourplex with single ownership, one permit is required
• Multipk 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 in No
0 County ❑ City of Spokane Valley
APPLICANT SIGNATURE: ./ f DATE: 6 243'-0-6
er or Contractor (circle one)
Method of Payment:
D Cash D 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