2006, 08-07 Permit App: 06005469 SewerSpokane County Division of Utilities, —LI (-
w
SEWER CONNECTION PERMIT APPLICATION FORM &=
PLEASE NOTE: This application form must be filled out accurately and in its entirety, and signed, or a permit will not be issued. Sewer permits are valid for 12
months form the date of issuance. A separate right-of-way permit is required for any work performed in or from the public right-of-way. All intenor
plumbing and electrical work requires separate permits.
Job Address:
PROJECT INFORMATION
�y
Parcel Number: 4156 Lp 3 . U��� Lot: Block:
Project Name:
V1.I1) Name:
CHECK APPLICABLE BOXES
❑ Regular
❑ Dry Sewer
❑ Repair
❑ Addition
❑ Abandonment
VIesidential Cl New
Commercial O New
13 Temporary
Owner's name: ./7) rA ` ,-1 i6)
.Address: t (/C4 S.i lr`." 1' j/{j ci-c
City/State: 5 )7? -t.4, Gi,
Zip:
Phone: 0 /C? 7
* FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMING THE INSTALLATION MUST FIRST CONTACT THE
UTILITIES DIVISION BEFORE PERMITS) CAN BE ISSUED.
SIGNATURE OF UTILITIES DIVISION PERSON CONTACTED:
Contractor (company name):
Sate contractor license number: j / j _ �Pf'},
Business address:
City/State: 91470 -F -...-1-1--e/ t .49 Ltp 2L ? 3
Contact Name:
Phone Number:
Cfln
e/cr
INTERIOR PLUMBING ALTERATIONS? (yes/ Isacle one
Fill out the information in the table below if applicable**
/* County 0 City of Spokane Valley
Contractor (if different from above): Phone:
Business Address: City/State/Zip
**For Spokane County plumbing reversal fee information, see reverse side of this foem.
/ FEE INFORMATION
Number of Buildings connecting to sewer l X (times) 5100 (per bldg) = S + $10.00 = SPOK ANF couN'n
RIGHT or WAY PERMIT
• For a single-family residential unit, one permit is required;
• For a condominium, townhouse, duplex, triplex or fourplex with separate ownership (as determined by lot lines) separate address and separate stub, one permit is required per address per stub;
• For a single budding 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 any of the work to be performed in or frthe public right-of-way? CI Yes No
Coun City of Spokane Valley
APPLICANT SIGNATURE:
Owner or Contractor (circle
DATE: 9-
Method of Pa env
O Cash [d Check
O Visa 0 MasterCard 0 Discover Card
ate: Expires:
IBankcard Number:
Authorized Signature:
Spokane County Department of Building and Planning
1026 West Broadway avenue' Spokane WA 99260
To. No. (509) 477-3675' Fax No. (509) 477-7198* TDD No. (509) 477-7133
PLUMBING PERMIT APPLICATION
•
PROJECT
ADDRESS:
PERMIT
USE:
OWNER:
PHONE (Daytime Contact):
MAILING ADDRESS:
(Street) (City/State) (Zip)
CONTRACTOR:
LICENSE:
MAILING ADDRESS:
PHONE:
(Street) (City/State) (Zip)
PLUMBING FIXTURES
DESCRIPTION
DETAIL
# OF
UNIT
S
MULTI-
PLIED
BY
COST/
UNIT
EQUALS
AMOUNT
TOILETS
WATER CLOSETS, BIDETS
x
$6
=
URINALS
-
x
$6
=
TUBS
-
x
$6
=
SHOWERS (per trap)
BATH, STALL, ON-SITE BUILD
x
$6
=
SINKS
LAVS/BASINS, BAR, FLOOR, KITCHEN,
LAUNDRY, UTILITY, JANITOR, PHOTO, X-
RAY, FOOD (PREP/CULINARY/MEAT
x
$6
=
DISHWASHER
-
x
$6
=
CLOTHES WASHER
-
x
$6
=
GARBAGE DISPOSAUGRINDER
-
x
$6
=
WATER SOFTENER
-
x
$6
=
ELECTRIC HOT WATER TANKS
(NOTE: if gas water tank see mechanical)
x
$6
=
FLOOR DRAINS
AREA, CASE, COIL, TRENCH,
CONDENSATE
x
$6
=
ROOF DRAINS/OVERFLOW DRAINS (ea.)
-
x
$6
=
FOUNTAINS, DRINKING
-
x
$6
=
WATER PIPING/DRAIN-IN WASTE-
VENT/PLUMBING REVERSALS
INSTALLATION, ALTERATION, REPAIR,
REVERSALS
x
$6
=
SEWAGE EJECTORS
GRINDER, SUMP PUMP
x
$6
=
WATER USING DEVICES
ICE AND/OR COFFEE MAKER, HOSE BIB,
STEAMER, PROOFER, CARBONATOR,
SWAMP COOLERS
x
$6
=
CROSS CONNECTION DEVICES
VACUUM BREAKER, CHECK VALVE, AND
R.P.B.P.D. FOR : VATS, SUMPS, TANKS,
BOILERS, & SPRINKLER SYSTEMS
X
$6
=
INTERCEPTORS
GREASE TRAP, SAND TRAP, CHEMICAL
HOLDING TANK
x
$6
=
MEDICAL GAS (per outlet/bottle station)
NITROUS, OXYGEN
x
$6
=
MISCELLANEOUS FIXTURES
-
X
$6
=
METHOD OF PAYMENT
SUBTOTAL
PLUS: NON-REFUNDABLE
PROCESSING FEE
$ 25.00
• CASH ■ CHECK ■ VISA IN MASTERCARD ■ DISCOVER
FAXED PERMITS WILL ONLY BE ACCEPTED WITH PAYMENT OF A MAJOR CREDIT CARD
DATE: EXPIRES:
SUBTOTAL: MINIMUM PERMIT
FEE IS $35.00
PLUS: 16% REGIONAL PLANNING
SURCHARGE
BANKCARD NUMBER:
TOTAL PERMIT FEE DUE
AUTHORIZED SIGNATURE:
Spokane County Department of Building and Planning
1026 West Broadway Avenue * Spokane, WA 99260-0050
Telephone No. (509) 477-3675 * Fax No. 477-7198 * TDD No. (509) 477-7133