2007, 05-20 Permit App 07003170 SewerSpokane County Division of Utilities
SEWER CONNECTION PERMIT APPLICATION FORM
PLEASii NO" IT: 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 fog;any work performed in or from the public right-of-way. a interior
plumbing 'ant! electrical work requires separate permits.
PROJECT INFORMATION
Job Address: j� %�
Parcel Number: "/ J ( � ' 1�tf' 1)
Proicct Name: i
U1.i1) Name:
I.ot: Block:
CHECK APPLICABLE BOXES
UY Regular
❑ Dry Sewer
❑ Repair
❑ Addition
D :abandonment
LEI Kesidential 0 New
O Commercial 0 New
O Temporary
Owner's name:
Address:
City/State:
Zip:
170
'5./1 w1
Phone:
* 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 CON'IAC77 D: /21/6-7
Contractor (company name):
Business address: k 4 t . p,
City/State: (� isle, Zip: /�j LEI
Sate contractor license number.
Contact Name:
kM,I4-6 L (Z,h6
Phone Number. LJ ' 0
INTERIOR PLUMBING ALTERATIONS? (yes no circle one
Fill out the information in the table below if appkcab/e*
❑ County ❑ City of Spokane Valley
Contractor (if different from above): Phone:
Business Address: City/State/Zip
**For Spokane. Connate p1v nbeg reversal fee information; .we irrnrrre thie tois formal .
FEE INFORMATION
Number of Buildings connecting to sewer X (times) S100 (per bldg) = S + $10.00 = SPOKANE COUNTY
RIGHT OF WAY PERMIT
• For a single-famJy 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 budding duplex, triplex or fourplex with single ownership, one permit is required
• Multiple buildings (apartments, industrial complexes) with single ownership, one permit required per budding 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 public right-of-way? Cl Yes No
0 County 0 City of Spokane Valley
APPLICANT SIGNATURE: r (.tM'� ZD V7
�-^—"V DATE:
Owner or Contractor (circle one)
Method of Payment:
0 Cash
0 Check 0 Visa
0 MasterCard 0 Discover Card
Date: Expires:
Bankcard Number:
AuthorizedSignature:
Spokane County Department of Building and Planning
1026 West Broadway Avenue'Spokane WA 99260
Tsl. No. (509) 477-3675 * Fax No. (509) 477-7198' 71)D No. (509) 477-7133