2000, 01-31 Permit App: 00000559 SewerSpokane County Division of Utilities f tY'r C�
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 form the date of issuance. No extensions will be granted.
PROJECT INFORMATION
Job Address: %' 9 f/.7 cr�l/?i'k f (i"6 e
Parcel Number: V& 3 14 01/03 Lot: 3 Block: q
CHECK APPLICABLE BOXES
lit Regular
,4 I* Dry Sewer
❑ Repair
Cl Addition
❑ Abandonment
Residential 0 New
O Commercial 0 New
O Temporary
Owner's name: / /eGf/? 5, tote o 60e-
Address:
Ce
Address: /J j ,cu c/ /,t (C )21e-
c
City/State: Oft, , /s(J»
Zip: ff Z /
Phone: S 3 V3
.s FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMING THE INSTALLATION MUST FIRST CONTACT THE
UTILITIES DMSION BEFORE PERMITS) CAN BE ISSUED.��_ ��
* SIGNATURE OF UTILITIES DIVISION PERSON CONTACTED: .!�
CONTRACTOR INFORMATION
Sate contractor license number:
Contractor (company name):
Business address:
City/State: Zip:
Contact Name:
Phone Number:
INTERIOR PLUMBING ALTERATIONS? (yes/no) circle 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) $100 (per bldg) _ $
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 SITUATIOINS NOT VERED H C THE COUNTY DIVISION OF UTILITIES AT 477-3604)
APPLICANT SIGNAT DATE:
Method of Payment:
0 Cash 0 Check
0 Visa
0 MasterCard 0 Discover Card
Date: Expires:
Bankcard Number:
Authorized Signature:
Spokane County Division of Building & Planning
1026 West Broadway Avenue * Spokane WA 99260
Tel. 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)
LICENSE:
CONTRACTOR:
MAILING ADDRESS:
PHONE:
(Street) (City/State) (Zip)
PLUMBING FIXTURES I
DETAIL
# OF
UNITS
MULTI- -
PLIDESCRIPTION
BY
COST/
UNIT
EQUALS
AMOUNT
B02
TOILETS
WATER CLOSETS, BIDETS
x
56
—
B03 ^
URINALS
x
56
—
B04
TUBS
-
x
56
—
B05 :
SHOWERS (per trap)
BATH, STALL, ON-SITE BUILD
x
$6
—
B06
SINKS
LAVS/BASINS, BAR, FLOOR,
KITCHEN, LAUNDRY, UTILITY,
JANITOR, PHOTO, X-RAY, FOOD
(PREP/CULINARY/MEAT
x
56
—
B07
DISHWASHER
-
x
56
—
B08
CLOTHES WASHER
-
x
56
—
B09
GARBAGE DISPOSAL/GRINDER
-
x
$6
—
B10 :
WATER SOFTENER
-
x
$6
—
B11
ELECTRIC HOT WATER TANKS
(NOTE: if gas water tank see
mechanical)
x
$6
—
B12
FLOOR DRAINS
AREA, CASE, COIL, TRENCH,
CONDENSATE
x
56
—
B13
ROOF DRAINS/OVERFLOW DRAINS
(ea.)
-
x
$6
—
B14I,
FOUNTAINS, DRINKING
-
x
, $6
—
B15
WATER PIPING/DRAIN-IN WASTE-
VENT/PLUMBING REVERSALS
INSTALLATION, ALTERATION,
REPAIR, REVERSALS
x
56
—
B16
SEWAGE EJECTORS
GRINDER, SUMP PUMP
x
$6
—
B17
WATER USING DEVICES
ICE AND/OR COFFEE MAKER,
HOSE BIB, STEAMER, PROOFER,
CARBONATOR, SWAMP COOLERS
x
$6
—
B18
CROSS CONNECTION DEVICES
VACUUM BREAKER, CHECK
VALVE, AND R.P.B.P.D. FOR :
VATS, SUMPS, TANKS, BOILERS, &
SPRINKLER SYSTEMS
$6
—
B19,
INTERCEPTORS
GREASE TRAP, SAND TRAP,
CHEMICAL HOLDING TANK
x
$6
—
B20 "
MEDICAL GAS (per outlet/bottle station)
NITROUS, OXYGEN
x
56
—
B21
MISCELLANEOUS FIXTURES
56
—
METHOD OF PAYMENT
VISA 11,
SUBTOTAL
PLUS PROCESSING FEE
$ 25.00
• CASH
■ CHECK ■ .MM. ■
FAXED PERMITS WILL ONLY BE ACCEPTED
OF A MAJOR CREDIT
EXPIRES:
= - ! � •
WITH PAYMENT
CARD
DATE:
BANKCARD
AUTHORIZED
TOTAL PERMIT FEE DUE
MINIMUM PERMIT FEE IS $35.00
PLEASE MAKE CHECKS PAYABLE TO
SPOKANE COUNTY PERMIT CENTER
NUMBER:
SIGNATURE:
Spokane County Division of Building & Code Enforcement
1026 West Broadway Avenue * Spokane, WA 99260-0050
Telephone No. (509) 477-3675 * Fax No. 477-7198 * TDD No. (509) 477-7133
UTILITIES DIVISION
N. Bruce Rawls, P.E., Utilities Director
A DIVISION OF THE PUBLIC WORKS DEPARTMENT
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.
Date:
Jrnti. 3/, 02000
Plat Name: C_ -i to r
Lot No(s): 3 Block No(s):
Site Address(es): )t'. W/5 5tifiny cet`-2 Parcel No(s): «b lv4'• 1)
VO
Owner Name: %PClY1 ' LUf/ l ,Ou)-e_ OR Builder Name:
Payment Option Selected (Check One):
1. ( ) GFC payment received at issuance of Sewer Connection Permit by
Division of Utilities
2.
(
) GFC to be paid at closing.
3. (X) GFC payment in 24 equal monthly payments upon establishment of Sewer Billing Account.
Complete one of the following statements.
a. Owner's Statement: I, sem' , understand that I will be
billed for the applicable Gamount in 24 monthly installments. The monthly GFC installments will be added
to my monthly sewer service charges.
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 billings as soon as
billing commences.
Special Conditions: (j.) No ( ) Yes — See Reverse Side of Form
3/ oZDO C)
wn s or Builder's Signature Date
Spokane County,UU�GFC Payment Option Form
DivisionofW Utilities dway • Spokane, WA 99260-0180 • (509) 477-3604 FAX: (509) 477-4715 TDD: (509) 3Revised
-3X71 y00
Special Conditions (continued, as needed, from reverse side of form):
Spokane County,
Division of Utilities
GFC Payment Option Form
Revised 01/12/00