2001, 07-06 Permit App: 01005468 Sewer . . •
Project Number: 01005468 Inv: 1 Application Date: 7/6/2001 Page 1 of 1
THIS IS NOT A PERMIT
Penalties will be assessed for commencing work without a permit
Project Information:
Permit Use: DRYLINE SEWER-SHELLEY ACRES ADD Contact: LEXINGTON HOMES
Address: 12218 NEZ PERCE LN
C-S -Z: SPOKANE WA 99206
Setbacks: Front Left: Right: Rear: Phone: (509)924-1519
Group Name:
Site Information: Project Name:
Plat Key: 005705 Name: SHELLEY ACRES District: F
Parcel Number: 45244.0905 Block: 2 Lot: 5
SiteAddress: 1008 5 STEEN CRT Owner: Name: SHELLEY ACRES SUBDIVISI
VERADALE,WA USA 99037 Address: 14522 E VALLEYWAY AVE
Location::VER SPOKANE,WA 99206
Zoning: SR-1 Suburban Residential 1
Water District: Hold: ❑
Area: 1.31 Acres Width: 0 Depth: 0 Right Of Way(ft): 50
Nbr of Bldgs: 1 Nbr of Dwellings: 1
Re aew In
f
Department Review ( }
UTILITIES Review by Utilities Released By: ( rec -�'
Hold Reasons: �, `
Permit Conditions: u91 � /(ojit seK2G
Sewer Permit
Contractor: FOLSOM EXCAVATING INC Firm: FOLSOM EXCAVATING
Address: 16701 E VALLEYWAY AVE Phone: (509)891-1232
VERADALE,WA 99037
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
Payment Summary: :::. ... .,
Operator: MKC Printed By: MKC Print Date: 7/6/2001
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
FLOOD PLAIN WATER DIST REQ'D FIRE DIST REQ'D
e--»^.�- - �.. 4=:. x„+c_ l�� c.;; Jpokane.(.�ain}`�'y�1l1VLSloa of Ut111ileS '� "��o-Yrkre;�e�"�, .!?'?F *- ,.;�.•�
• 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.
Also note that sewer permits are valid for 12 months from the date of issuance. 'No extensions will be granted.
PROJECT INFORMATION
Job zddr-.s: j Dry Line Owner's name:
tOg . Sewer?(Y/N) Aff/ES ��C•
Lit ,��
City: t A /�. � 1C City/State: SFt3,C-A,A- / GOA
Zip: *(1F / Zip: qg zoCo
Parcel number(if known): Phone: (s :)9) 92 J51
115A crgc45---
First-time contractors or home-owners performing the installation must first contact the utilities department(in person or via phone
[456-3604])before a permit can be issued. _
Name of Utilities Division person contacted:
CONTRACTOR INFORMATION -
Contractor(company name): State contractor license number:
- 3L Q-12 i- 7 '-- } �OLSOE ;7 0 33 7)a.
Business address: Contact Name:
. /Co 7d/ ( -
City/State: (.;E,eG.L
Zip: 9 .O3/7 Phone: S0'� ) 8 9/-/Z30- Phone: (6 09) 9 7z3--(eOOZ
INTERIOR PLUMBING ALTERATIONS? (yes/no) (t:one
Fill out the information in the table below if applicable**
Contractor(if different from above): Phone:
Business Address: City/State/Zip:
* ` tar htnel in reversal ee h >See �Td a this ore <€'=
- FEE INFORMATION
Sewer Connection: Number of Buildings / )(Nines)$100(per bldg) =$ 700
TOTAL FEE
• 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 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 @ 456-3604)
APPLICANT SIGNATURE: Date:
Return(Ix
Spokane County Division of Buildrng&Planning
(Vest 1026 Broadway At nue*Spokane,Washington 99260
PHONE:(509)456-3675 *FAX:(509)324-3198*TDD:(509)324-3166
Spokane Counq does not dtaautanxe on the bans of duabthq m the daemon to,ot treatment en employment in,is pcogam or activities tensteeehaeeemenene
• •:., a•',41..`..." .M'1!A."• .(.jtj•. ."'•.xdrr!i..A•
r%„�w I.'•�_u£,+'.., • e -7.41.errarn.-;'• -e-^r_.;,',),""'r.•.; r*.t.r w.=,"*M0:.:",r,. •-'T t'..si.,.>
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' '`�' C O U N T Y
UTILITIES DIVISION IS. A DIVISION OF THE PUBLIC WORKS DEPARTMENT
N.Bruce Rawls,P.E.,1ltiities 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.
ate: —7 6 G
1
Plat Name: C) '---1/41----
/ Lot No(s): Block No(s): —
41,
Site Address(es): 0 0 I 1 J ,6-
rcel No(s): SA 411 , () 7C 55
Owner Name:
OR Builder Name: i.o/U&�C / AmE--5///le-•
PRINT Owner's Name PRINT Builder's Name
Payment Optica Selected (Check One):
1. ( ) GFC payment received at issuance of Sewer Connection Permit by
Division of Utilities
2. ( ) GFC to be paid at dosing,at the GFC rate in effect at the time of closing.
3. ( ) GFC payment in 24 equal monthly payments upon establishment of Sewer Billing Account.
Complete one of We 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 wilt be added
to my monthly sewer service charges.
b. Builder's Statement: 1. , 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: ( ) No ( ) Yes –See Reverse Side of Form
Spokane County, GFC Payment Option Form
Division of Utilities Revised 03/06/00
1026 W,Broadway • Spokane, WA 99260-0180• (509)477-3604 FAX: (509)4774715 TDD: (509)324-3166