2014, 07-23 General Facilities Charge UtilitiesSPOKAI.
LLT!LITIES DIVISION
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GENERAL FACILITIES CHARGE (GFC) - PAYMENT OPTION SELECTION RECORD
PLEASE NOTE: Form must be filled out accurately and in its entirety, and signed, prior to permit issuance.
Date: 7/a3fIY Plat Name: Wivcreics1 Qloyak kocK Lot No(s): e(O Block No(s):
Site Address(es): /( /L( E. gvcrc/c.)i j . 4?.1 4/4 - 7ProGParcel No(s):
Owner Name: CIO X10 �� OR Builder Name:
PRINT Owner's Name PRINT Builder's Name
Use of Property: Single family )( , Duplex , Multi -Family Commercial
GFC Calculation: ERUs assigned , GFC Rate $ per ERU, GFC Amount $
Note: See Special Conditions below regarding GFC rates.
Payment Option Selected (Check One):
1. ❑ GFC payment received at issuance of Sewer Connection Permit by
Amt Paid Check # Receipt # Division of Utilities Staff Person
2. ® GFC to be paid at closing. Allowable only if property will be sold prior to occupancy.
3. ❑ GFC payment in 24 equal monthly payments upon establishment of Sewer Billing Account.
If Option No. 3 is selected, complete one of the following statements:
a. Owner's Statement: 1, , understand that I will be
billed for the applicable GFC amount in 24 equal monthly installments. The monthly GFC installments will be
added to my monthly sewer service charges.
b. Builder's Statement: I, , understand that because I
am selecting this option for payment of the GFC, the purchaser of the home will be responsible for payment of
the applicable GFC in 24 equal monthly installments. I agree to formally disclose to potential buyers of the
property that the GFC charges will be added to the first 24 monthly sewer service billings.
Special Conditions: I understand that the charges outlined above are based on the current use of the property.
Future changes in use of the property or increased water usage on commercial properties may result in the
requirement to pay additional Sewer Connection Charges. I also understand that sewer connection permits are
valid for one year from the date of issuance. If the sewer connection is not fully completed and inspected within the
one-year life of the permit, a new permit will be required, and the Sewer Connection Charges will be recomputed
based upon the rates in effect on the issuance date of the new permit.
Other Conditions: 0 No ❑ Yes (If yes, detail on reverse side of form)
7/�3/Ay
Owner's or Builder's Signature Date
Accepted by Division of Utilities Date
1026 West Broadway Avenue, 4th Floor — Spokane, WA 99260-0430
PHONE: (509) 477-3604 — FAX: (509) 477-4715 TDD: (509) 477-7133
Spokane County, Division of Utilities
GFC Payment Option Form, Revised 7/29/2013