2002, 03-13 Permit App: 02001488 Sewer Spokane County Division of Utilities
SEWER CONNECTION PERMIT APPLICATION FORM
PI.1'.ASF,NOTE: This application form must be filled out accurately nd in its entirety,and signed,or a permit will not be issued. ,\lso note that sewer permits are
valid for 12 months form the date of issuance. No extensions will be granted. A separate right-of-way permit is required for any work performed in or from
the county right-of-way.
f ��j PROJECT INFORMATION
Job Address:'' `—` IX- '4)�
Owner's name: 41iEl- DC Ib eL'IJ
Parcel Number: Lot: / Block: /�
Project Name: c_SIF�Y Address: 745 /,}�)- /ViLi.O e.JCl'CSY
ULIL)Name: <''
City/State: =-- /4 /L A.
CHECK APPLICABLE BOXES
U Regular PI Residential 1gi New
Zip: 99Q)la
U Dry Sewer 0 Commercial 0 New --,---:-7- '' ��)—h �
Phone: C'
U Repair 0 Temporary
❑ Addition
❑ Abandonment
* FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMING THE INSTALLATION MUST FIRST CONTACT THE
UTILITIES DIVISION BEFORE PERMIT(S)CAN BE ISSUED.
SIGNATURE OF U'I'IITilES DIVISION PERSON CONTACTED:
Contract> > a y name): Sate contractor license number:
li i5 �')C A VATiv'/
Business address: Contact Name:
City/State: Zip:
Phone Number:
INTERIOR PLUMBING ALTERATIONS? (yes no) c cle one
Fill out the information in the table below if applicable*
Contractor(if different from above): Phone:
Business,Address: City/State/Zip
**For plumbing reversal fee information,see reverse side of this form.
FEE INFORMATION
Number of Buildings connecting to sewer X (times)S100(per bldg)=S + S10.00=
Ioct rr OEAx_01 PERMIT
• Eur a single-family residential unit,one permit is required;
• Pur a condominium,townhouse,duplex,triplex or fourples with separate ownership(as determined be lot lines)separate address and separate stub,one permit is required per address per stub;
• lair 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' 1x-of the work to be performed in or from the county right-of-way? 0 Yes 0 No
xPPLICANT SIGNATURE:
Method of Payment: DATE:
❑ Cash 0 Check 0 Visa 0 MasterCard 0 Discover Card
Date: Expires:
Bankcard Number:
Authorized Signature:
PLUMBING PERMIT APPLICATION
r
PROjILCL' �'� PERMIT
ADDRESS: ,-.D.A.,// ) •/'2LS/ AIX .44/ USE: --Ni
OWNER:
t,t-� —2e.-.71?// ,,,
7E/ /1,�� PIIONI; (Daytime Contact):
MAILING ADDRESS:71.
(Street) (City/State) (Zip)
CONTRACTOR: ---� LICENSE:
dYL-2.4=4✓ 9J"i&fa, 9/8.1 /AT/in/4 T6- %/Zing I1.4T/mr ' /2 d.2P
MAILING ADDRESS: PIIONi::
:j�l- gS/- `l - 7-4-;W--7.5-2'7
7,P, Al. iViz_zlxt)Jee r// 40/e- L-)6
(Street) (City/State) (Zip)
PLUMBING FIXTURES
#OF MULTI- COST/ AMOUNT
DESCRIPTION DETAIL PLIED
UNITS BY UNIT EQUALS
B02 TOI1,E'I'S WATER CLOSETS,BIDI:I'S 3 x S6 _ /5
B03 URINALS v. SO
B04 TUBS SO _ gB05 SI IOWERS(per trap) BA'1'II,S'I'AI,L,ON-SITE BUILD x SO =
/g
B06 SINKS 1,AVS/BAS7NS,BAR,FLOOR, x SO =
KITCHEN,LAUNDRY,U'I'II.1'1'Y,
JANITOR,P11010,X-RAY,FOOD i
(PRI P/CULINARY/MEAT yO
B07 DISIIWASIIER - / x S6
CO
B08 CLOTI IFS WASHER - / S6 =
B09 GARBAGE DISPOSAL/GRINDER x SO h
B10 WATER SOFTENER - Q SO =
B11 ELECTRIC 1101'WATER TANKS (NOTE: if gas water tank see mechanical) -- p x SO =
B12 FLOOR DRAINS AREA,CASE,C011,1RENCI I, N SO =
CONDISNSATE
B13 ROOF DRAINS/OVI:RI7,OW DRAINS(Ca.) - x SO =
B14 FOUNTAINS,DRINKING N SO
B15 WAFER PIPING/DRAIN-1N WASTE- INSTALLATION,ALTERATION, x SO =
VENT/PLUMBING RI?V'f:;RS:AI,S REPAIR,Rl:V ERS:U,S
B16 SEW.\GE EJECTORS GRINDER,SUMP PUMP / x SO = h
B17 WATER USING DEVICES ICE.AND/OR COFFEI'.M:AKI R,I LOSE x SO =
BIB,SIl?.ASMI?R,PROOI'I?R,
C2RBON:ATOR,SWAMP COOI.IERS 4. 1/
B18 CROSS CONNECTION DEVICES VACUUM BRE.AKI:R,Cl IECK V':AI.VI(, SO =
AND R.P.B.P.D.FOR: V'A'l'S,SUMPS,
TANKS,BOILERS,&SPRINK],I:R
SYS'FEMS
B19 INTERCEPTORS GREASE TRAP,SAND TRAP, s SO =
CI IE,MICAL,I IOI.DING"I'_ANK
B20 MEDICAL.GAS(per outlet/bottle station) NITROUS.OXYGEN s SO =
B21 MISCE],1,ANIOUS FIXTURES
SO =
METHOD OF PAYMENT
SUBTOTAL
MIIIIIM ICIOVE
VISA PLUS PROCI.SSING1,1'I; S 25.00
❑ CCASH ❑ CHECK EI
❑ ❑ ,„
I\XI(D 1,1.1i\III.s\VIl.l.ONLY BC \CCEP H D\\1711 1'.\Y\II\F
Or_A AI goR CRFD1.1(;.ARD
TOTAL PI:RMIT FIT:DUI(
D:A'1'I': I?XPIRI?S: MINIMUM PERMIT FEE IS$35.00
PI,EASI:MAKE CI IECKS P_AY.ABI,E'1'0
BANKC:1RD NUMBER: SPOKANE COUN'11 PERMIT CENTER
:\UTI IORIZED SIGNATURE:
Spokane Count Division of Building&Code I(ntorcement
1(120 West Broadway Avenue ' Spokane,WA 99200-0(1511
Telephone No.(5119)477-3075* Fax No. 477-7198`'1'UD No. (5119)477-7133