2002, 07-30 Permit App 02006421 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.
`�� PRO ECTF INFORMATION
Job Address: % �'a_1 7 r (°//�� Ca
Parcel Number:
Project Name:
ULID Name:
Lot: Block:
LOO bi t., �l-
CHECK APPLICABLE BOXES
❑ Regular
0 Dry Sewer
O Repair
❑ Addition
❑ Abandonment
O Residential 0 New
O Commercial 0 New
O Temporary
Address:
City/State:
Zip:
Phone:
Owner's name: A cc, e
q a3n dc
qa c(-"do
Is any of the work to be performed in or from the county right-of-way?
Yes'' 0 No
r:" 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:
Cont_ r (cpmpany
tm ro---ns /r/.(!t
Sate contractor licensp n
z/�PS e
r0 77 i/
Business address: % -
City/State: 5p 0 /� 11 /iU tl Zip: 9 .2/ �}
Contact Name'---n/J
Phone Number: /—// / V?
INTERIOR PLUMBING ALTERATIONS.(/no) circle one
Fill out the information in the table below ifapp icable',E
ntr for (if differe om abov ):
Business Address:
3`-//e-/
Phone:
3-
City/State/Zip
FFOS
s*Foz plumbing reversal fee information, see reverse side of this: form.
Number of Buildings connecting to sewer
FEE INFORMATION
' X (times) $100 (per bldg) =
S 10.00 = /( cre
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 lints) s irate address and separate stub, one permit is required per
address per stub;
• For a single building duplex, triplex or fourplex with single ownership, onr 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 477-3604)
APPLICANT SIGNATURE:
DATE:
Method of Payment:
❑ 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) 477-7195 " 1 DD No. (509) 477-7133
PLUMBING PERMIT APPLICATION
PROJECT
tJ
PERMIT
ADDRESS:
v �/
USE:
o OWNER: -e— n
L !
PHONE (Daytime Contact):
P
LING ADDil
Sweet
(City/State
i
C
LICENSE:
w iA
MAILING ADDRES :
PHONE:
(Street)
Ci /State)
i
PLUMBING FIXTURES
N OF
MULTI
COST/
AMOUNT
DESCRIPTION
DETAIL
UNITS
PBYD
UNIT
E UALS
B02
TOILETS
WATER CLOSETS, BIDETS
x
S6
B03.
URINALS
x
S6
B04
TUBS
x
$6
B05
SHOWERS (per trap)
BATH, STALL, ON -SITE BUILD
x
S6
-
BO6
SINKS
LAVSBASINS, BAR, FLOOR,
x
S6
-
KITCHEN, LAUNDRY, UTILITY,
JANITOR, PHOTO, X-RAY, FOOD
REP/CULINARY/MEAT
B07
DISHWASHER
x
$6
B09
CLOTHES WASHER
x
S6
B09
GARBAGE DISPOSAIJGRINDER
x
$6
-
BIO
WATERSOFTENER
x
S6
B11
ELECTRIC HOT WATER TANKS
(NOTE: if gas water tank see
x
$6
-
mechanical)
B12
FLOOR DRAINS
AREA, CASE, COIL, TRENCH,
x
$6
=
CONDENSATE
B13
ROOF DRAINS/OVERFLOW DRAINS
-
x
S6
=
ea.
B14
FOUNTAINS, DRINKING
x
$6
B15
WATER PIPING/DRAIN-IN WASTE-
INSTALLATION, ALTERATION,
x
$6
=
VENT/PLUMBING REVERSALS
REPAIR, REVERSALS
B16
SEWAGE EJECTORS
GRINDER, SUMP PUMP
x
$6
B17
WATER USING DEVICES
ICE AND/OR COFFEE MAKER,
x
S6
=
HOSE BIB, STEAMER, PROOFER,
CARBONATOR, SWAMP COOLERS
BIS
CROSS CONNECTION DEVICES
VACUUM BREAKER, CHECK
$6
=
VALVE, AND R.P.B.P.D. FOR:
VATS, SUMPS, TANKS, BOILERS, &
SPRINKLER SYSTEMS
B19
INTERCEPTORS
GREASE TRAP, SAND TRAP,
x
S6
e
CHEMICAL HOLDING TANK
B20
MEDICAL GAS (per outlet/bottle station
NITROUS, OXYGEN
x
$b
B21
MISCELLANEOUS FIXTURES
S6
METHOD OF PAYMENT
SUBTOTAL
PLUS PROCESSING FEE
S 25.00
El CASH
[-]CHECK ❑ ElVISA
❑
FAXED PERMITS WJU ONLY BE ACCEPTED WITH PAYMENT
OF A MAJOR CREDIT
CARD
TOTAL PERMIT FEE DUE
DATE: EXPIRES:
MINIMUM PERMIT F£E IS S35.00
PLEASE MAKE CHECKS PAYABLE TO
BANKCARD NUMBER:
SPOKANE COUNTY PERMIT CENTER
AUTHORIZED
SIGNATURE:
Spokane County Division of Building & Code Enforcement
1026 West Broadway Avenue " Spokane, \VA 99260-0050
Telephone No- (509) 477-3675 * Fax No. 477-719S ° TDD No. (509) 477-7133