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