2001, 06-08 Permit App: 01004462 SewerProject Number: 01004462 Inv: 1
Application
THIS IS NOT A PERMIT
Penalties will be assessed for commencing work without a permit
Project Information:
............................................
Permit Use: SEWER CONNECTION - SHELLEY LAKE 3RD
ADD
Date: 6/8/2001 Page 1 of 1
Setbacks: Front
Site Information:
Plat Key: 006156 Name: SHELLEY LAKE 3RD ADDITION
Left: Right: Rear:
Contact: GEORGE H WHITE INC
Address: PO BOX 52
C - S - Z: LIBERTY LAKE, WA 99019
Phone: (509) 921-9752
Group Name:
Project Name:
District: F
Parcel Number: 45245.9000 Block: 3
SiteAddress: 856 S SHELLEY LAKE LN
GREENACRES, WA USA 99016
Location:: GRE
Zoning: UR -3.5 Urban Residential 3.5
Water District: 010 VERA
Area: 8,488 Sq Ft Width: 70 Depth: 113 Right Of Way (ft): 30
Nbr of Bldgs: 1 Nbr of Dwellings: 1
Review Information:
Lot: 2
Owner: Name: GEORGE H WHITE INC
Address: PO BOX 52
LIBERTY LAKE, WA 99019
Hold: ❑
Department
UTILITIES
Permits:
Review
Review by Utilities
Released':.
I ✓
Hold Reasons: t7 • TO t5vi t E. ,L)11_01Nty ri-F-M I T C2/)LX , "T 11-41.9 ,-rt ME -
Permit Conditions:R. WC-
A/M T ifWHE)
UifED 5 L ,Z ti/s /fZ t C40`
Contractor: UNKNOWN
Address: UNKNOWN
UNKNOWN, WA UNKNOWN
Item Description
SEWER CONNECTION
PROCESSING FEE
Payment Summar v: ;:;:;:;
Operator: MKC
Permit Type
Sewer Permit
Notes:
Sewer Permit
Firm: UNKNOWN
Phone: (000) 000-0000
Units Unit Desc
1 NUMBER OF
1 Y OR BLANK
Printed By: MKC
Permit Total Fees:
Fee Amount
$85.00
$15.00
$100.00
Print Date: 6/8/2001
Fee Amount Invoice Amount Amount Paid Amount Owing
$100.00 $100.00
$100.00
$100.00
$0.00 $100.00
$0.00
$100.00
S P O k A N E
UTILITIES DIVISION
N. Bruce R.twls, P.E., Utilities Director
Date: ZIA-lki f% k
a
O U N -r
A DIVISION OF THE PUBLIC WORKS DEPARTMENT
GENERAL FACILITIES CHARGE (GFC)
PAYMENT OPTION SELECTION RECORD
Site Address(es): e3.3-70
Parcel No(s):
c14% 9%37
Builder Name: C.eo r -Se_ 14 • wN i 7wG OR Owner Name:
Payment Option Selected (Check One):
1. ( ) GFC payment received at issuance of Sewer Connection Permit by
Q. (X) To 6 Pat ckk CA oS t n Division cf 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 for the applicable GFC amount in 24 monthly installments. The monthly GFC
installments will be added to my monthly sewer service charges.
Owner's 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 cf 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 billjngs as soon as billing comments.
`I
Builder's A
Spokane County,
Division of Utilities Revised 1/26/99
I
ori ,epre� ative's Signature
OFF 15r
Date
GFC Payment Option Form
1026 W. Broadway • Spokane, WA 99260-0130 • (509) 477-3604 FAX: (509) 4774715 TDD: (509) 324-3166