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2003, 02-28 Permit App: 03001223 Sewer Spokane County Divisicau 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. ,llso 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: �/V l t� "a 'b G Parcel Number: Owner's name: Lot: Block: Project Name: Address: -744 j „ 1041" ULID Name: lJ CHECK APPLICABLE BOXES I City/State: 3\ _ Regular 0 Residential 0 New Zip: ❑ Dry Sewer O Commercial O New CIRepair 0 'Temporary Phone: ❑ Addition ❑ Abandonment * 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: lntr/ac't�or(company name): Sate contractor license number: Lsclrc" ►lctet; Oe ,e Business address: /7"S"/6&' w p ,,2 Contact Name: City/Stat(6v ee e•✓ 14./CA Zip: 770/4 Phone Number: INTERIOR PLUMBING ALTERATIONS? circle one Fill out the information in the table below if applic .e 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)S100(per bldg)=S + S10.00= • for a single-family residential unit,one permit is required; 12161 If OF WAY Pt:I0117' • for a condominium,townhouse,duplex,triplex or foutplex 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 from the county right-of-way? Yes 0 No 'APPLICANT SIGN:A'TURF• DATE: Method of Payment: Cash 0 Check 0 Visa 0 MasterCard 0 Discover Card Date: Expires: Bankcard Number: Authorized Signature: Spokane County Division of Building&Code I?nforcement 11126\Vest Broadway.Avenue*Spokane WA 992611 Tel.No.(5o9)477-3675 ' Fax No.(5119)4T,-7198*"IDD No.(5119)477-7133 PPPr PLUMBING PERMIT APPLICATION PROJECT PI.RMIT ADDRESS: USE: OWNER: P1 IONE (Daytime Contact): �LAl1.1NC;ADDRESS: (Street) (City/State) (Zip) CONTRACTOR: LICENSE: MAILING ADDRESS: PI IONE: (Street) (City/State) (Zip) PLUMBING FIXTURES I #OF MULTI-D COST/ AMOUNT PLIE DESCRIPTION DETAIL UNITS BY E UNIT EQUALS B02 TOILETS WATER CLOSET'S,BIDETS x S6 = B03 URINALS x $6 B04 TUBS - x $6 = B05 SI LOWERS(per trap) BATI I,SPALL,ON-SITE BUILD x $6 = B06 SINKS LAVS/BASINS,BAR,FLOOR, x $6 = KI'I'C1 II?N,I,AUNDRY,UTILITY, JANITOR,PI KYI'O,X-RAY,IR)OI) (PRI',P/CU].1NARY/ME,AT B07 DISIIWASIII?R - x 56 = B08 (TOMES WASI LER - x S6 = B09 GARBAGE DISPOSAL./GRINDER - x 56 = BIO WATER SOFTENER - x S6 = Bll I T.ECI'RIC 110'1'WA'I'I'.R'1ANKS (NOTE: if gas water tank see mechanical) x S6 = B12 FLOOR DRAINS AREA,C-ASI:,COI1,,TRI'NCI I, x S6 = CONDENSATE B13 ROOF DRAINS/0V'ERF],OW DRAINS(ca.) - x 56 = B14 FOUNTAINS,DRINKING - x $6 = B15 WATER PIPING/DRAIN-IN WASTE- INSI'AI.1.A'1'ION,A1;I'ERATTON, x S6 = VENT/PLUMBING REVERSALS REPAIR,REVERSALS B16 SEWAGE ESI:C'I'ORS GRINDER,SUMP PUMP x S6 = B17 WATER USING DEVICES ICE AND/OR COFFEE MAKER,110SE x SO = BIB,SIT?AMER,PROOII(R, CARBONA'I'OR,SWAMP COOLERS B18 CROSS CONNEC'T'ION DEVICES VACUUM BREAKER,CI IECK VALVE, S6 = AND R.P.B.P.D.FOR: VAT'S,SUMPS, TANKS,BOILERS,&SPRINKLER SYSTEMS B19 INTERCEPTORS (iREASE'1'RAP,S\NL)TRAP, x SO = (:1 IEMICAI.I IOLDING'TANK B20 N11(DICAl.GAS(per outlet/bottle station) NITROUS,OXYGI'N x S6 = B21 MISCELLANEOUS FIXTURES SO = METHOD OF PAYMENT SUBTOTAL VISA PLUS PROCESSING FEE S 25.00 ❑ (:\SI I ❑ c:1 iNcK 0 MIN= ❑ ❑ I'.\Xi t)PFR\/rs\\ll.l.O\1.Y nl: U:ct:t'ITD\\'Ili P\\An: •i• ut v yi Tuts asF:nrr e uRD '1'01'\1.PERMIT FEE DUI' D.\'I'I:: EXPIRES: MINIMUM PERMIT FEE IS$35.00 B.ANKC.ARD NUMBI(R: PLEASE MAKE CHECKS PAYABLE TO SPOKANE COUNTY PERMIT'CENTER AUTI I I(RIZI:l)SIGNATURE: Spokane County Division of Building&Code Enforcement 1026 West Broadway:Avenue" Spokane WA 992611 Tel.No.(509)477-3675' Fax No.(509)477-7198'IDD No.(509)477-713.3