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2004, 08-05 Permit App: 04005740 SewerSpokane County Division of Utilities _ SEWER CONNECTION PERMIT APPLICATION FORM d 7€3t0 Spokane 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 performSd in or from the county i h -of -way:. L0' d 1 a n C{ 4' Nt✓' �� dJ C INFORMATION Job Address: 7 00 I L— 9/ -1 - Parcel Parcel Number: Project Name: ULID Name: Lot: Block: CHECK APPLICABLE BOXES ❑ Regular ❑ Dry Sewer O Repair O Addition O Abandonment O Residential 0 New O Commercial 0 New O Temporary Owner's name: Tip YY1 1? p 0 l Address: 7 0 0/ 6 City/State: _Sr- Zip: Y Phone: c.535 36,3r FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMING THE INSTALLATION MUST FIRST CONTACT THE UTILITIES DIVISION BEFORE PERMIT(S) CAN BE ISSUED. SIGNATURE OF UTILITIES DIVISION PERSON CONTACTED: C=2 -actor (company name); t 1 Sate contract r license n mb C®L4 KC S2t ISS i IS 7 Business address: L City/Stat(�2 c Zip: G,/ Ej Contact Name: D. CS U KC1Na. I C.a (4 Phone Number: aL\ INTERIOR PLUMBING ALTERATION no) circle one Fill out the information in the table below if app icable** 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) = $ + $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 in or f om the county ight-of-way.l Yes 0 No APPLICANT SIGNATURE: DATE: 9 3c( Method of Payment: ❑ Cash ❑ Check ❑ Visa 0 MasterCard 0 Discover Card Date: Expires: Bankcard Number: 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: PERMIT USE: OWNER: PHONE (Daytime Contact): MAILING ADDRESS: (Street) (City/State) (Zip) CONTRACTOR: LICENSE: MAILING ADDRESS: PHONE: (Street) (City/Stat PLUMBING PIXTURP_S DESCRIPTION DETAIL # OF UNITS MULTI- PEYD COST/ UNIT EQUALS AMOUNT Bb2.'_. TOILETS WATER CLOSETS, BIDETS 56 - 'iBOY : URINALS x 56 - 1304 r TUBS - a 56 - SORE SHOWERS (per trap) BATH, STALL, ON-SITE BUILD 56 - B06' SINKS LAVSBASINS, BAR, FLOOR, KITCHEN, LAUNDRY, UTILITY, JANITOR, PHOTO, X-RAY, FOOD (PREP/CULINARY/MEAT x 56 - RV DISHWASHER - z 56 R08' CLOTHES WASHER - x 56 - B09 GARBAGE DISPOSAL/GRINDER - 56 BIO WATER SOFTENER - x S6 - E11„ .-• ELECTRIC HOT WATER TANKS (NOTE: if gas water tank see mechanical) x 56 B12 FLOOR DRAINS AREA, CASE, COIL, TRENCH, CONDENSATE x 56 - B13. ROOF' DRAINS/OVERFLOW DRAINS (ea) - x 56 914 ' FOUNTAINS, DRINKING - 56 B15 - WATER PIPING/DRAIN-IN WASTE- VENT/PLUMBING REVERSALS INSTALLATION, ALTERATION, REPAIR, REVERSALS x 56 - B16 SEWAGE EJECTORS GRINDER, SUMP PUMP 56 - B17 WATER USING DEVICES ICE AND/OR COFFEE MAKER, HOSE BIB, STEAMER, PROOFER, CARBONATOR, SWAMP COOLERS x 56 - 18-±-3 EIS - CROSS CONNECTION DEVICES VACUUM BREAKER, CHECK VALVE, AND R.P.BPD. FOR : VATS, SUMPS, TANKS, BOILERS, & SPRINKLER SYSTEMS 56 - B)9* INTERCEPTORS GREASE TRAP, SAND TRAP, CHEMICAL HOLDING TANK x 56 - B24 " MEDICAL GAS (per outlet/bottle station) NITROUS, OXYGEN x 56 - B21:y MISCELLANEOUS FIXTURES 56 - METHOD OP PAYMENT SUBTOTAL PLUS PROCESSING FEE $ 25.00 VISA:Ci- ❑ CASH ❑ CHECK ❑ 11.131111I1 ❑ 0 FAXED PERMITS WILL ONLY BE ACCEPTED WIRE PAYMENT OP A MAJOR CREDQ CARD DATE EXPIRES: . TOTAL PERMIT FEE DUE MINIMUM PERMIT FEE'S 335.00 PLEASE MAKE. CHECKS PAYABLE TO SPOKANE COUNTY PERMIT CENTER EANKCARD NUMBER: Arm-TnRIZFD SIGNATURE: Spokane County Division of Building & Code Enforcement 1026 Wm Broadway Avenue * Spokane, WA 99260-0050 Telephone No. (509) 477-3675 * Fax No. 477-7198 *TDD No. (509) 477-7133