2010, 04-21 Permit App: 10001754 Sewer riP_r ,,t) euoi 4: IUPM SPUKHNE#CUUNTY#UTILITIES 4777178 P, 1
SEWER R PERMIT APPLICATION ID ___,Li
S okane Coun Division of Utilities
Phone: (509)477-3604 Fax:(509)477-4715
This appl icadon form must be filled out accurately and in its entirety and signed or a permit will not be issued. Only one Permit shall
he issued per Application. Sewer permits are valid for 12 months from the date issuance.
First time contractors or home owners performing the installation must receive orientation/consultation from the Division of
Utilities Division.
Jlomeowve
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Irrctal/otiaits:I agree to have consultation prior to performing any work.
VU'( `�`x'�'r 'L ! lo INSTALLER'S INFORMATION(P EASE PR1Ir)
Contractor frump..-.Na,e):Ch A '1.14 y,.,r1Stg State License Number:CHT�.IO4-'1C3
.----
Business Address: P() i. .i). /�� Name: Ch i...15 N10.1101/
City/StaterZip: . -)i) 11
_ kvvt .1. Phone: 10 -,1 1 4-2-
PROD& —10(/
INFORMATION Wm/am PRrrrr9
Job Address: 1 O
-� 3 a. 2 2 I.a?'1 e, CHECK APPLICABLE BOXES
Parcc! Number •CJ 2`F 1.�3C�bl Lot: Connection to Sewer }� New Construction
I_ Block: 0 Dry Side Sewer
osier
ProJeci PlatName: �H� d3-O� ❑ Repair 0 Commercial
0 Alteration to Existing Sewer ❑ Temporary
Ovri,r";Name: jarL.of FA 11+ te..td 0 Abandorunent 0 Accessory Building
Addres _ Z.d C Vsl. fro r -h�t vet, ]p},. 0 Main/Manhole Tap/Cut-In 0 Trap/Separator
0 Private Sewer Extension(no building conneclions)
City/S:atelZip�?a ICA re_; WA 4 A zol Other
Phone
INTERIOR PLUMBING ALl ERATIONS Yes ❑ No 14 (All interior plumbing and electrical work requires separate permits.)
r u noir, Crn tractor ?carne: Phone:
1V YF K'PO I.PERFORMED IN OR FROM THE PUBLIC RIGHT-OF-WAY •i4Yes , I No
If yes,a se urate permit to work in the right-of-way is required from the appropriate agency.
APPLICANT , ( I TE- EN'f 2P)Zt5 L aik�IGNATURE: ei1 4 /7'lt eu DATE: Y-Z/-l67
(Please Priam) Owner ore ntract tcirde one)
PEE CALCULATION-to be completed by the Division of Utilities
Each Land Parcel connecting t.,the sewer must have a separate permit. One permit fee is required per building connecting to the
sewer. I o cep:ion: Ycnnection of accessory buildings as de.Sned wider SCC 8.03.6040(f)may be included under the permit applica-
tion nod fee for the primary s ructure. Additional inspection charges nay be applicable per SCC 8.03.6040(a).
Number of buildings connectitgto sewer: _1 X $125 permit fee =$ IS.°"1"
Number of Sewer Iviain Marhole Taps: X$125 tap fee =$
Private tiewer rxtension .'Dry Side Sewer X $125 permit fee =$____________
Repairs, Aheratiors. Abandon::ients&Other X $125 permit fee =$
+$ 15.00 Applicstion Foe ao
Total Permit Fee=$ 11.1••0.
***-.lpplicahlc GFC, SCC CFR,or Latecomer Fees may be due prior to issuance of a Sewer Permit.****
MIL IT!ES CONI ACT SEC NATURE:CA'SiCti-, } tiG1.�vt/1 DATE: 141Z el f?
Special Perini:Concitions: CpF C.. f
f0I'Ila S It nP✓O ST .1 PiVt) wine,
METHOD OF PAYMENT
o Cash 0 Check 0 Visa 0 MasterCard 0 Discover
Bankcard Number: Expiration Date: ___ . _
•
Authorized Signature:
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