2004, 05-24 Permit App 04003533 SewerSpokane County Division 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. 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 or from the county right-of-way_
PROJECT INFORMATION
Job Address
/16o!;L Gv L
Parcel Number:
Project Name:
ULID Name:
Lot: Block:
CHECK APPLICABLE BOXES
❑ Regular
❑ Dry Sewer
D Repair
❑ Addition
❑ Abandonment
O Residential O New
D Commercial 0 New
O Temporary
Owner's name: L) Rp 1---\'
Address ! / 60 2 E c�
City/State: E
Zip:
Phone:
Is any of the work to be performed in or from the county right-of-way? 0 Yes* I . 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 CONTAU 1 E1):
Contractor (company name):
Business address:
City/State:GikP e ., Pt- S (!3. Zip: q 9Q [ ��
Sate
e I be OLie IC —1
Contact Name-
u ai a e co
u t�chaln,
Phone Number. 9 aP-y -, j"I a 4J
INTERIOR PLUMBING ALTERATIONS: es/no) circle one,46._
Fill out the information in the table below if op-
Contractor (if different from above): Phone:
Business Address:
City/State/Zip
FEE INFORMATION
Number of Buildings connecting to sewer X (times) $100 (per bldg) = $ + $10.00
RIGHT OF WAY PERMIT
• For a angle -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 dup]cx, triplex or fourplex with angle ownership, one permit is required
• Multiple buildings (apartments, industrial complexes) with angle ownership, one permit required per building connecting to the sewer.
(FOR SITUATIONS NOT COVERED HERE, CALL THE COUNTY DIVISION OF UTILITIES AT 477-3604)
APPLICANT SIGNATURE: DATE:
Method of Payment:
0 Cash 0 Check
0 Visa
0 MasterCard ❑ Discover Card
Date: Expires:
Bankcard Number.
Authorized Signature:
Spokane County Division of Building & Code Enforcement
1026 West Broadway Avenue' Spokane WA 99260
Tel. No. (509) 477-3675 " Fax No. (509) 477-7198 * TDD No. (509) 477-7133
PLUMBING PERMIT APPLICATION
PROJECT
ADDRESS:
PERMIT
USE
OWNER:
PHONE (Daytime Contact):
MAILING ADDRESS: -
(Sheet) (City/State)
CONTRACTOR
7SCENSE:
MAILING ADDRESS:
PHONE
(Street) (City/State) (Zip)
PLUMBING FIXTURES I
DESCRIPTION
DETAIL
# OF
UNITS
PLIED
ar
COST/
UNIT
EQUALS
AMOUNT
TOILETS
WATER CLOSETS, BIDETS
x
56
—
URINALS
z
56
—
TUBS
-
x
56
—
SHOWERS (per trap)
BATH, STALL, ON -SITE BULD
_ x
56
—
+1-
SINKS
LAVS/BASINS, BAR, FLOOR,
KITCHEN, LAUNDRY, UTILITY,
JANITOR, PHOTO, X-RAY, FOOD
(PREP/CULINARY/MEAT
x
56
—
DISHWASHER
-
z.
56
-
-
CLOTHES WASHER
-
x
56
—
GARBAGE DISPOSAL/GRINDER .
-
x
56
—
B.
WATER SOFTENER
-
x
56
—
!
ELECTRIC HOT WATER TANKS
(NOTE if gas water tank see
mechanical)
x
56
—
F
FLOOR DRAINS
AREA, CASE, COJL TRENCH,
CONDENSATE
z
56
—
ROOF DRAINS/OVERFLOW DRAINS
(ea)
-
z
56
FOUNTAINS, DRINKING
-
- x
56
—
WATER PIPING/DRAIN-INWASTE-
VENT/PLUMIiING REVERSALS
INSTALLATION, ALTERATION,
REPA)R, REVERSALS
x
56
SEWAGE EJECTORS
GRINDER, SUMP PUMP
r
S6
—
.,.
WATER USING DEVICES
ICE AND/OR COEEttMAXER,
HOSE BIB, STEAMER, PROOFER,
CARBONATOR, SWAMP COOLERS
x
56
—
-
CROSS CONNECTION DEVICES
VACUUM BREAKER, CHECK
VALVE, AND R-PR.P-D- FOR :
VATS, SUMPS, TANKS, BOILERS, &
SPRINKLER SYSTEMS
56
—
li.
INTERCEPTORS
GREASE TRAP, SAND TRAP,
CHEMICAL HOLDING TANK
x
56
—
MEDICAL GAS (per outlet/bottle station)
NITROUS, OXYGEN
x
56
—
MISCELLANEOUS FIXTURES
$6
—
METHOD
El CASH
DATE
BANKCARD
AUTHORIZED
OF PAYMENT
'VISA
❑ .CHECK ■❑L
FAXED PERMITS WILL ONLY PEACCEPTED
OF A MAJOR CREDIT
EXPIRES:"ry
SUBTOTAL
PLUS
PROCESSING FEE
$ 25.00
i'C.-t
-. 0
WITH PAYMENT
CARD
.
TOTAL PERMIT FEE DUE
t
` ..w}..-_
M1
v(
rr.'�'
�,..
�£ •
NUMBER
SIGNATURE
Spokane County Division of Building & Code Enforcement
1026 Wen Broadway Avenue' Spokane, WA 99260-0050
Telephone No- (509) 477-3675 ' Fax No. 477-7198 * TDD No- (509) 477-7133