2000, 01-31 Permit App: 00000576 SewerSEWER CONNECTION PERMIT APPLICAtivLN r•�•••
This application form must be filled out accurately and in its entirety, and signed, ori permit will not be issued. Also note
PLEASE NOTE: PPbextensionsO
that sewer permits are valid for 12 months form the dace of issuance. No EON t �J
PRO ECT INFORM
Job Address: _
Parcel Number:
❑ Regular
❑ Dry Sewer
❑ Repair
❑ Addition
• Abandonment
COriTR-kCTORS OR HOME OWNERS PERFORMING THE INSTAI.LkTION MUST FIRST CONI ACT THE
::• FIRST ES �i��� Y� J �7L-nL�ES DItiZSION BEFORE PERtifIT(S) C�1N BE ISSUED.
::• SIGNATURE OF UTILITIES DIVISION PERSON CONTACTED:
CONTRACTOR INFORMATION
Sate contractor license number:
VionuroCAK UT -
C)3 ( -Y0 Lot: + ' _ Block:
CHECK APPLICABLE BOXES
Residential O New
O Commercial 0 New
O Temporary
Owner's name:
Address:
C �G(� In2� lv Pr
City/State: q�
Zip:
Phone: 30
Contractor (company name): k.e) Gt
Business :address:
City/State:
Zip:
Contact Name:
Phone Number:
�
ver
IN'T'ERIOR PLUMBING ALTERATIONS. (,/no ) circle one
Fill out the information in the table below ifaanlicable"
Phone:
City/State/Zip
Business Address:
**For Dlumbinreversal fee information, see reverse side of this ; 0777•.
FEE INFORMATION
�_ X (times) SICC (per bldg) - 5
Number of Buildings connecting to sewer
• For a single-family residential unit, one permit is required:
• For a condominium, townhouse, duplex, triples or fourplex with separate ownership (as determined by lot lines) separate 3cdress and separate stub, one permit is requiredper
address per stub;
• with sin a ownerop,
For a single building duplex, triplex or fourplex with single ownership, one permit is required
Multiple buildings (apartments, industrial complexes) nione permit required per building connecting to :he sewer.
COUNTY DIVISION OF UTILITIES AT 477- 6C4)
•
(FOR SITUATION NOT COVERED ERE, CALL `
Contractor (if different from above):
TOTAL. FEE
a PPLIC'LNT SIGNATURE:
Method of Paytn t: Cl Visa
0 Cash Check
Date:
Bankcard Number:
Authorized Signature:_
❑ MasterCard
Expires:
DATE:
0 Discover Card
Spokane County Division of Building & Planning
1026 West Broadway Avenue * Spokane WA 99260
Tel. No. (509) 477-3675 ' Fax No. (509) 477.4703 * TDD No. (509) 324-3166
S P Cr k A N E ':-;'` ,'�;,,_ ,�s C O U N T Y
UTILITIES DIVISION A DIVISION OF THE PUBLIC WORKS DEPARTMENT
N. Bruce Rawls, P.E., Utilities Director Gary Oberg, Director
GENERAL FACILITIES CHARGE (GFC)
PAYMENT OPTION SELECTION RECORD
PLEASE NOTE: Form must be filled out accurately and in its entirety, and signed, or a permit will not be issued.
Date:
Plat Name:
/311 .2_13b
Site Address(es):
Owner Name:
1302 /7%€40,_ #/Lot No(s): �O
a i `i N _ Shamrock_ et
Block No(s):
Parcel No(s): ^4 5(,0 1, ea3C c%
(ram./ tadd (i OR Builder Name:
Payment Option Selected (Check One):
1. ( ) GFC payment received at issuance of Sewer Connection Permit by
Division of Utilities
2. ( ) GFC to be paid at dosing.
3. ) GFC payment in 24 equal monthly payments upon establishment of Sewer Billing Account.
Complete one of the following statements.
a. Owner's Statement: I, k&C 1' `/ Wake t GeACI , understand that I will be
billed for the applicable GFC amount in 24 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, that 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 monthly sewer service billings as soon as
billing commences.
Special Conditions: (J( ) No ( ) Yes — See Reverse Side of Form
/
Owner's or B
I 3 + 1,o -c -f -z.)
`kms
e s Signatur Date
Spokane CoUu�ntty, GFC Payment Option Form
DivisionRevised
W.1Broadway • Spokane, WA 99260-0180 • (509) 477-3604 FAX: (509) 477-4715 TDD: (509) 324-316601/12/00