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