2001, 09-24 Permit App: 01008294 SewerSpokane County Division of Utilities
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. A separate right-of-way permit is
required for any work performed in or from the county right-of-way.
PROJECT INFORMATION
Job Address:
N 9.0 3 i,,,/oo dCv {'{�
Parcel Number:4 5l 7 2 • 1 `
Project Name: l v/( l—%) LAT
UL'e:
CHECK APPLICABLE BOXES
• R
_ e
l
❑ Repair
❑ Addition
❑ Abandonment
f9'Residential D New
O Commercial O New
O Temporary
Owner's name: Kirby 4 eL e/%c•4-s
Address: I/ 9o3 Lt%(iY>Gf'/`U i4
City/State: L.11) U' /C CA
Zip:
oG
Phone:
FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMING THE INSTALLATION MUST FIRST CONTACT THE
UTILITIES DIVISION BEFORE PERMIT(S) CAN BE ISSUED. l cV
SIGNATURE OF UTILITIES DIVISION PERSON CONTACTED:
"------
Contractor
0/11 company rhe):
e�-
Sate contractor license number:
Business address:
City/State:
Zip:
Contact Name:
Phone Number:
INTERIOR PLUMBING ALTERATIONS / o) circle one
Fill out the information in the table below if . /ble"
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 1 X (times) $100 (per bldg) = $ 1 tlC/• + $10.00 =
RIGHT OF 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 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 any of the work to be performed inor from e county right-of-way? O Yes CYNo
APPLICANT SIGNATURE:
Method of Payment:
O Cash
0 Check 0 Visa
Date:
Bankcard Number:
DATE: 7 2 y O/
0 MasterCard 0 Discover Card
Expires:
Authorized Signature:
Spokane County Division of Building & Code Enforcement
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: a ai,
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
A OF
UNITS
MU"'-
Pay
COST/
UNIT
EQUALS
AMOUNT
B02
TOILETS
WATER CLOSETS, BIDETS
x
$6
—
B03,
URINALS
x
$6
—
B04
TUBS
-
x
$6
—
B05'
SHOWERS (per trap)
BATH, STALL, ON-SITE BUILD
x
$6
—
B06a
' _'
,
SINKS
LAVS/BASINS, BAR, FLOOR,
KITCHEN, LAUNDRY, UTILITY,
JANITOR, PHOTO, X-RAY, FOOD
(PREP/CULINARY/MEAT
x
$6
—
B073
DISHWASHER
-
x
$6
—
BOR*
CLOTHES WASHER
-
x
$6
—
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
$6
—
B13-
ROOF DRAINS/OVERFLOW DRAINS
(ea.)
-
x
$6
—
B14'
FOUNTAINS, DRINKING
-
x
$6
—
B15
.
WATER PIPING/DRAIN-IN WASTE-
VENT/PLUMBING REVERSALS
INSTALLATION, ALTERATION,
REPAIR, REVERSALS
x
$6
—
-:
1316
SEWAGE EJECTORS
GRINDER, SUMP PUMP
x
$6
—
B17
"
WATER USING DEVICES
ICE AND/OR COFFEE MAKER,
HOSE BID, STEAMER, PROOFER,
CARBONATOR, SWAMP COOLERS
x
$6
-
B18R
CROSS CONNECTION DEVICES
VACUUM BREAKER,
VALVE, AND R.P.B.P.D.
VATS, SUMPS, TANKS,
SPRINKLER SYSTEMS
CHECK
FOR :
BOILERS &
$6
-
B19
INTERCEPTORS
GREASE TRAP, SAND TRAP,
CHEMICAL HOLDING TANK
x
$6
—
1320
MEDICAL GAS (per outlet/bottle station)
NITROUS; OXYGEN
x
$6
—
B21
MISCELLANEOUS FIXTURES
_
$6
—
METHOD
0 CASH
DATE:
BANKCARD
AT TTHrlRI7FT)
OF PAYMENT
VISAh
SUBTOTAL
PLUS PROCESSING FEE
$ 25.00
v
a1C!`�
• CHECK 0 •
FAXED PERMITS WILL ONLY BE ACCEPTED
OF A MAJOR CREDIT
EXPIRES:
■
WITH PAYMENT
CARD
TOTAL PERMIT FEE DUE
MINIMUM PERMIT FEE IS $35.00
PLEASE MAKE CHECKS PAYABLE TO
.. SPOKANE COUNTY PERMIT CENTER
NUMBER:
STCiNATI TRF.:
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