2007, 10-24 Permit App: 07007429 Sewer Spokane County Division of Utilities
SEWER CONNECTION PERMIT APPLICATION FORM
P).E.\S1:NOTE: This application form must be filled out accurately and in its entirety.and signed,or a permit will not be issued. Sewer permits are valid for 12
months form the date of issuance. A separate right-of-way permit is required for any work performed in or from the public riht- -w . All interior
plumbing and electrical work requires separate permits. ) 2:1 Jr
PROJECT INFORMATION LI
Job Address: ((/10 ( /J ) / �/
.<-, 1 i Owner's name: //9/ tr: / 0 /94P
Parcel Number. L�� 1.ot: 9 Block:
Project Name: 13 l< 44 ' I L4 Fin. .\ddress: 65 a 3 1-1 t n eb u,P2 C�
U1.I1)Name:
City/State: C2QnVe1Clle C'
CHECK APPLICABI,,E BOXES
Regular ,�/Residential $ New Zip: 9566 d
D Dry Sewer O Commercial O New Phone ('9/6) '702 9— 02203
0 Repair O Temporary
U Addition
U Abandonment
* FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMII THE INSTALLATION MUST FIRST,CONTACT THE
UTILITIES DIVISION BEFORE PERMIT(S)CAN BE ISSUED. rr `1` ( CC
SIGNATURE OF UI-11.1"17ES DIVISION PERSON CONTAcrED: /Ott ti� \� /i i? S/6�Y D /a/ i4rO7
Contractor(company name): Sate contractor license number:
Business address: Contact Name:
City/State: Zip:
Phone Number.
INTERIOR PLUMBING ALTERATIONS? (yes/no) circle one
Fill out the information in the table below if applicable**
D County D City of Spokane Valley
Contractor(if different from above): Phone:
Business Address: City/State/Zip
**For Spokane County plrmrbing reversal fee information,see mem.tide of tbirform.
FEE INFORMATION
Number of Buildings connecting to sewer X(times)S100(per bldg)=S + S10.00= SPOKANE.COUNTY
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,triples or fourplex with single ownership,one permit is required
Multiple buildings(apartments,industrial complexes)with sine ownership,one permit required per building connecting to the sewer.
(FOR SITUATIONS NOT COVERED HERE,CALL THE COUNTY DIVISION OF UTILITIES AT 477-3604)
s any of the work to be performed in or from the public right-of-way? ❑ Yes ❑ No
D County D City of Spokane Valley
IPPLICANT SIGNATURE: DATE:
Owner or Contractor(circle one)
lethod of Payment:
] Cash 0 Check 0 Visa 0 MasterCard 0 Discover Card
Date: Expires:
Bankcard Number:
Authorized Signature:
Spokane County Department of Building and Planning
11126 West Broadway Avenue•Spokane WA 99260
Tel.No.(509)477-;675• Fax No.(509)477-7198'TDD No.(50 9)477-7133