2001, 06-08 Permit App: 01004459 SewerProject Number: 01004459 Inv: 1
' Application
THIS IS NOT A PERMIT
Penalties will be assessed for commencing work without a permit
Date: 6/8/2001 Page 1 of 1
Project Information:
Permit Use: SEWER CONNECTION - SHELLEY LAKE 3RD Contact: GEORGE H WHITE INC
ADD Address: PO BOX 52
C - S - Z: LIBERTY LAKE, WA 99019
Setbacks: Front Left: Right: Rear: Phone: (509) 921-9752
Group Name:
Project Name:
Site Information:
Plat Key: 006156 Name: SHELLEY LAKE 3RD ADDITION District: F
Parcel Number: 45245.9000
Block: 3 Lot: 6
SiteAddress: 844 S SHELLEY LAKE LN
GREENACRES, WA USA 99016
Location:: GRE
Zoning: UR -3.5 Urban Residential 3.5
Water District: 010 VERA Hold: I1]
Area: 10,225 Sq Ft Width: 70 Depth: 144 Right Of Way (ft): 30
Nbr of Bldgs: 1 Nbr of Dwellings: 1
Owner: Name: GEORGE H WHITE INC
Address: PO BOX 52
LIBERTY LAKE, WA 99019
Department
UTILITIES
Permits:
Review
Review by Utilities Release
Hold Reasons: Oke., TO k551,(f.--5E3E- 5FAL-11210-.& Tr—irl- ti- ON i.-kt AT 'TN \5 "runt .
Permit Conditions: APE e— i .60 wii _.l._. , i'diVeS /We 6a6.1.5E:40.
Fc' F0/2,41 516N -%-2,
Sewer Permit
Contractor: UNKNOWN Firm: UNKNOWN
Address: UNKNOWN Phone: (000) 000-0000
UNKNOWN, WA UNKNOWN
Item Description Units Unit Desc Fee Amount
SEWER CONNECTION 1 NUMBER OF $85.00
PROCESSING FEE 1 Y OR BLANK $15.00
Permit Total Fees: $100.00
Operator: MKC Printed By: MKC Print Date: 6/8/2001
Permit Type Fee Amount Invoice Amount Amount Paid Amount Owing
Sewer Permit $100.00 $100.00 $0.00 $100.00
$100.00
$100.00
$0.00 $100.00
UTitmEs DIVISION
N. Bruce Rawls, P.E., Utilities Director
A DIVISION OF THE PUSUC WORKS DEPARTMENT
GENERAL FACILITIES CHARGE (GFC)
PAYMENT OPTION SELECTION RECORD
Date: 3- N O Parcel No(s):
Site Address(es): e ley sie i tel i. e ; . kJ / lie I4 d,4 (e 5/037
Guilder Name: 6. eo r5 e._ (4 • RAI trjw G OR Owner Name:
Payment Option Selected (Check One):
1. ( ) GFC payment received at issuance of Sewer Connection Permit by
1.0- (X) -co 6 Fa.; k OA'0 5 t h Cl Division e Utilities
2. ( ) GFC payment in 24 equal monthly payments upon establishment of Sewer Billing Account.
Complete one of the following statements.
a. Owner's Statement: I, , understand that I will
be billed fcr the applicable GFC amount in 24 monthly installments. The monthly GFC
installments will be added to my monthly sewer service charges.
Owners Signature Date
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 bilIngs as soon as billing comments.
ocF vHy�
Builder's Aoriz-ed epresentative's Signature
Spokane County,
Division of Utilities
A
Date
GFC Payment Option Form
Revised 1/26/99
10=6 W. Broadway • Spokane, WA 99260-0130 • (509) 477-3604 FAX: (509) 477-4715 TDD: (509) 324-3166