2006, 06-28 Permit App: 06004391 SewerSpokane County Division of Utilities
SEWER CONNECTION PERMIT APPLICATION FORM
PLEASE NOTE: This application form must be filled out accurately and in its (AHiway, 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: `/ / L' .3 , C-1 /-7 /
'' 2
Parcel Number:t1�✓{d3 4.4A-5"1/ al, Lot: Block:
Project Name: Cr'I� y % 41'
ULID Name: l• �V F�+t
CHECK APPLICABLE BOXES
Regular
tODry Sewer
• Repair
❑ Addition
O Abandonment
alrResidcntial
O Commercial
0 Temporary
O New
O New
Owner's namel X44" d ..e•V-eSc/e
Address:
2/ --So odi e iai
City/State:(. ` (41/44'047 iLe /)CI
Phone: !...."--13,1 0 c:;'1--7 4
* FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMING TME INSTALLATION MUST FIRST CONTACT THE
' UTILITIES DIVISION BEFORE PERMIT(S) CAN BE ISSUED.
SIGNATURE OF UTILITIES DIVISION PERSON CONTACTED:
Contractor (company name):
INLAND EXCAVATING
Business addifisCONSTRUCTION, INC.
3417 W. Olson Rd
City/State: D_er nark. UUA 99006 Zip:
Licensed & Bonded
#INLANEG99'3DN
Sate contractor ii4psAtiuDeEXCAVATING
& CONSTRUCTION, INC.
Contact Name: 3417 W. Olson Rd
Deer Park, WA 99006
Phone Number: Ucensed & Bonded
#TNLANEC995DN
INTERIOR PLUMBING ALTERATIONS? (ye
Fill ont the information in the tab/e be/ow if rrpr/irable
rcle one
Contractor (if different from above): Phone:
Busin& CONSTRUCTION, INC. City/State/zip
3417W Olson Rd
Deer Park, WA 99006
Lioet+s�d p yegdgabing reversal fee a formation, see reverse .ride of this form.
#INLANEC995DN FEE INFORMATION
X (times) $100 (per bldg) = S/LSO + S10.00 =
Rica tr of WAN' PERMIT
umber of Buildings connecting to sewer
l
For a single-family residential unit,.onc permit is required;
For a condominium, townhouse, duplex, triplex or fourplcx with separate ownership (as determined be 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 regwrcd per budding connecting to the sewer.
(FOR SITUATIONS NOT COVE : r, HERE, CALL THE COUNTY DIVISION OF UTILITIES AT 477-3604)
IS' any of the work to be perforl
;':r\PPLICANT SIGNATURE:
Method of Payment:
Cash 0. Check 0 Visa
from the cou
ri >. -U wav? 0 Yes,No
0 MasterCard 0 Discover Card
D.\TE: 677 Com"
Date: Expires:
Bankcard Number:
Authorized Signature:
Spokane County Division of Building & Code 1(nfitrccmcnt
1026 \Vest Broadway Avenue ' Spokane W. 99260
Tel. No. (509) 477-3675 + Fax No. (509) 177-7198 ' 'MD No. (509) -177-7133
4.