HomeMy WebLinkAboutUtility Application.pdf WATER/SEWER/STORM/BACKFLOW
UTILITY PERMIT
APPLICATION
Updated
March 2016
Physical Address: Mailing Address: Webpage & Email: Phone & Fax:
Auburn City Hall Annex, 2nd Floor 25 West Main Street www.auburnwa.gov Phone: 253-931-3090
1 East Main Street Auburn, WA 98001-4998 permitcenter@auburnwa.gov Fax: 253-804-3114
PROJECT INFORMATION
Check all that apply: Water Sewer Stormwater Backflow
Single Family Residence Commercial Duplex Multifamily: # of units______
Job site address:_________________________________ Zip:_________ Lot #:___
Tenant Name:_______________________________ Parcel #:_________________
Complex Name:______________________________ Building #:_____Suite #:____
For Condominiums – Building Name:____________________________ Unit #:____
For Mobile/Manufactured Homes – Park Name:___________________ Space #:___
Permit Numbers
WTR_______ - _________
SWR_______ - _________
STM _______ - _________
BFL_______ - _________
Parent Permit #
SCOPE OF WORK: _________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
APPLICANT Owner Contractor Other______________________________________________
Name:______________________________ Phone #:___________________ Email:_________________________
OWNER CONTRACTOR
Name:_______________________________________
Check this box if this is the primary contact
Contact Person:_______________________________
Address:_____________________________________
City:___________________ State:____ Zip:________
Phone:______________________Fax:_____________
E-mail: ______________________________________
Company Name: ________________________________
Check this box if this is the primary contact
Contact Person:_________________________________
Address:_______________________________________
City:___________________State:____ Zip:___________
Phone:_________________ E-mail:_________________
Auburn Business Lic#:_________ WA UBI#:___________
STORM APPLICATION
CIRCLE ONE: New Development Modification to Existing Development Grading Related
Total New Impervious Surface (sq ft):__________________ Total Area to be Disturbed (sq ft):_________________
Description of work:___________________________________________________________________________
SEWER APPLICATION
CIRCLE ONE: New Connection Side Sewer Repair Demo Capping Tenant Improvement
IS ANY WORK WITHIN THE PUBLIC ROW No Yes If so, Construction Permit required
I certify that I have read this application and declare under penalty of perjury that the information contained herein is correct and complete.
I agree to comply with all city and county ordinances and state laws relating to building construction and hereby authorize representatives of
this city to enter upon the above mentioned property for inspection purposes. I am either the owner of the property on this permit application,
the Washington State registered contractor for the work, or I represent the owner or contractor as signified above and am acting with the
owner’s/contractor’s full knowledge and consent.
PRINTED NAME:__________________________SIGNATURE:_______________________DATE:____________
WATER APPLICATION
Check all that apply:
DOMESTIC IRRIGATION FIRE COMMERCIAL/
INDUSTRIAL
Yes No Yes No Yes No Yes No
If Yes, Meter Size (in):
Existing Meter Box? Yes No Yes No Yes No Yes No
Chemicals Added? N/A Yes No Yes No Yes No
BACKFLOW – PREMISE
Purpose of Device Type of Device Size
(inches)
Number
of Devices
Location behind
Meter unless
infeasible
Irrigation –
Single Family Residence
Chemicals
Added?
Yes RPBA
No DCVA
Fireline –
Single Family Residence
Chemicals
Added?
Yes RPBA
No DCVA
Domestic –
Non-Single Family RPBA
Irrigation –
Non-Single Family
Chemicals
Added?
Yes RPBA
No DCVA
Fireline –
Non-Single Family
Chemicals
Added?
Yes RPDA
No DCDA
BACKFLOW – PLUMBING
Please complete the Mechanical /Plumbing Application
(FOR STAFF USE ONLY)
Domestic Water Meter Permit Fee: County Inspection Fee: Fireline Connection Fee:
Deduct Water Meter Permit
Fee:
Irrigation Water Meter
Fee:
Domestic SDC:
Irrigation Only Meter SDC:
Assessment
(________FF*$_________)
Paybacks:
Total Water Fees:
Sewer Permit Fee: SDC (______ RCE * Current SDC Fee): County Inspection Fee:
Assessment
(_______FF*$__________)
Paybacks: Total Sewer Fees:
Storm Permit Fee:
Level: 1 2 3
SDC (______ ESU * Current SDC Fee):
Assessment
(________FF*$_________)
Paybacks: Total Storm Fees:
Application Reviewed By:___________________________ Date:___________ Ok to Issue______________