2002, 05-30 Permit App: 02004208 Sewer ,1- SEWER CONNECTION PERMIT APPLICATION FORM
PLEASE NOTE: This application form must be filled out accurately and in itventirety,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 performed in os from the county right-of-way.
PROJECT INFORMATION
Job Address: 12J'Z`-t t R--171-
4'5-2'54
)2'5 4- 1 l D 4 Owner's name: 5
Parcel Number: Lot: Block:
Project Name: - Address: 1 Z 1
ULID Name: ," (4.4 t 1+�
U City/State: 6 PO K Ai C if t
CHEEK APPLICABLE BOXES
Regular /4
Residential 0 New Zip: Crt7 2.O Ca
Dry Sewer 0 Commercial D New
0 Repair 0 Temporary Phone: _y
O Addition
O Abandonment
Is any of the work to be performed in or from the county right-of-way?X Yes* 0 No
* 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:
Co,pptractor(company name): Sate contractor license number:
`tLLi 1, Sc&VCR- e_,A)6- (j l,iC5 j3 t> )Z-5-
Business
'Z5Business address: :3I 7tEVY► 1 iL) 7(L i Contact Name:
City/State: Ail Gl4 i- t-" U .Zip: d q Lr L2- /Yl ,f tptL7 t/Z
Phone Number: 9;Z.q - 30 V
INTERIOR PLUMBING ALTERATIONS? drir o) circle one
Fill out the information in the table below if applicable""
Contractor (if different from above): Phone:
Plus;
1Am Y r 'Lu Lair? 9;C2 -151–1- 1
Business Address: City/State/Zip
/qcq[CnFOLK l C3,� tJA1 4czi Gtr Gr'1o16,
Fo lambing reversalfee infornratroni see,r,avesestde`o 'this form
/ FEE INFORMATION l
Number of Buildings connecting to sewer [ X (limes) $100(per bldg) _ $ /00 • + $10.00= //0
RIGHT OF WAY PERMIT
• For a single-family residential unit,one permit is required;
• For a condominium,townhouse,duplex,triplex or fourplex with separate ownership(as determined by lot lines)separate address and separate stub,one permit is required per
address per stub;
• For a single building duplex,triplex or fourplex with single ownership,one permit is required
• Multiple buildings(apartments,industrial complexes)with single ownership,one permit required per building connecting to the sewer.
(FOR SITUATIONS NOT COVERED HERE.CALL THE COUNTY DIVISION OF UTILITIES AT 477-1604)
APPLICANT SIGNATURE: t 6. � DATE: �'5 0-`� 7
Method of Payment: (/ • Q
D Cash 0 Check 0 Visa 0 MasterCard 0 Discover Card
Date: — Expires
Bankcard Number:
Authorized Signature:
Spokane Count-Division of Building& Code Enforcement
1026 West Broachk ac A enue'Spokane WA 99260
Tel No (507)477-3675" Fax No (509)1;7 7195 TDD No (509)a-'7131
DRESS: J Z-I 7i 1'�- L'- (. 7141. USE.
I �f�
'NER= ,�, .,.• tErn r7/.t16 �c tr 2Si$Z
w---{�yt.% PHONE (Daytime Contact):
II._ING ADDRESS: {� - i��i
] 212y � z7Z , •
OP
SSn
( ) 0l✓C/J,tl�Lc1S f 1 Gj 2f)11
Street (City/State)
NTRACTOR: LICENSE:: (ZIP)
3 -i-f,014 y P f-u rrt 6 i.LJ 6- 5 i= i wp_=o -F y id IK
FLING ADDRESS: PHONE:
($1( f(v Ki--i( ba2-b.5-2-1 l
'Q , A..)A-c/2 -: 5-, pt,A51.I , ' q0/ ,
(Street) (City/State)
(ZtP)
PLUMBING FIXTURES I
#OF MULTI- COST/
DESCRIPTTON DETAIL UNITS
PLIEDAMOUNT
TOILETS WATER CLOSETS,BIDETS arUNm F4UnLs
URINALS
$6 - fn.00
TUBS - $6
SHOWERS(per.trap) BATH,STALL,ON-SITE BUILD S6
SINKS LA VS/BASINS,BAR,FLOOR, S6 63-O 0
KITCHEN,LAUNDRY,UTILITY, $6 -
JANITOR,PHOTO,X-RAY,FOOD
(PREP/CULINARY/MEAT
DISHWASHER
CLOTHES WASHER
- $6
GARBAGE DISPOSAL/GRINDER _ $6 -
WATER SOFTENER S6 -
-
ELECTRIC HOT WATER TANKS (NOTE: if gas water tank see Sb -
mechani x S6 _ •
FLOOR DRAINS AREA,CASE,COIL,TRENCH,
CONDENSATE S6
ROOF DRAINS/OVERFLOW DRAINS _
(ea.) s b6 -
FOUNTAINS,DRINKING
WATER PIPING/DRAIN-IN WASTE- INSTALLATION,ALTERATION, x b6
VENT/PLUMBING REVERSALS REPAIR,REVERSALS x bb
SEWAGE EJECTORS GRINDER,SUMP PUMP 69'
WATER USING DEVICES ICE AND/OR COFFEE MAKER, x $6
" S6 =
HOSE BIB,STEAMER,PROOFER,
CARBONATOR,SWAMP COOLERS
CROSS CONNECTION DEVICES VACUUM BREAKER,CHECK
VALVE,AND R.P.B.P-D_FOR: 56 =
VATS,SUMPS,TANKS,BOILERS,&
SPRINKLER SYSTEMS
INTERCEPTORS GREASE TRAP,SAND TRAP_
CHEMICAL HOLDING TANK S6
MEDICAL GAS(per outlet/bottle station) NITROUS,OXYGEN
MISCELLANEOUS FIXTURES x S6 =
S6 -
IOD OF PAYMENT
SUBTOTAL
(Q,0 J
v/S� 11CAYE
.SH ❑ CHECK 111111 ❑ PLUS PROCESSING FEE S 25.00
=MenFAXED PERMITS WILL ONLY BE ACCEPTED WITH PAYMENT
OFA MAJOR CREDIT CARD
TOTAL PERMIT FEED •a'
EXPIRES
MINIMUM PERMIT FFE IS$35.00
ARD NUMBER: PLEASE MARE CHECKS PAYABLE TO
SPOKANE COUNTY PERMIT CENTER
?RIZED SIGNATURE.
—
Spokane Couni3-D1 oion of Building& Code Enforcement
1026 West Broadway Avenue `Spokane_ WA 992600050
Telephone No. (509)47 7-3675 Fax No. 477 i 198 ' 1 DD No. (509)477-7133