2006, 10-13 Permit App: 06007376 SewerSpokane County Division of Utilities
SEWER CONNECTION PERMIT APPLICATION FORM
,E 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
mu.. is 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 lam' litt7 ✓ ! ;
Job Address: 104 ‘s•
Parcel Number.
Project Name:
ULID Name:
�-
0'15
S \PPLO
Lot: Block:
CHECK APPLICABLE BOXES
Regular
'U Dry Sewer
O Repair
❑ Addition
❑ Abandonment
Residential O New
O Commercial 0 New
0 Temporary
Owner's name: _ Q ( to L\ SF
Address: 3 i c AV Ff �`j /2 L
City/State:
Zip: (1 C/ i
Phone: L �� % [.� `� (/ r_ / `;� • '%�}
* FIRST TIME CONTRACTORS OR HOME OWNERS PERFOR11111`TG THE INSTALLATION MUST FIRST CONTACT THE
UTILITIES DIVISION BEFORE PERMIT(S) CAN BE ISSUED.
SIGNATURE OF UTILITIES DIVISION PERSON CONTACTED:
Contractor
contractor license number:
Business address:
City/State: Zip:
Contact Name:
Phone Number:
INTERIOR PLUMBING ALTERATIONS? (yes/
Fill out the information in the table below if applicable**
circle one
❑ County ❑ City of Spokane Valley
Contractor (if different from above): Phone:
Business Address:
City/State/Zip
**Por Spokane Coxnty-/iLwnbi sawrml fee iaf ini air mv, a jade ethieferx.--
Number of Buildings connecting to sewer
1
FEE INFORMATIONn ,1
X (times) $100 (per bldg) =
RIGHT OF WAY PERMIT
SPOKANE COUNTY
• 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 erfomied in or om the ublic right-of-way? O Yes 0( No
\,,❑ Coufity 1 ❑ City of Spokane Valley
Y A / / �} % -
APPLICANT SIGNATURE: � ' , r —�"� DATE:
er or ontractor (circle one)
Method of Payment:
O 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