1996, 08-27 Permit App: 96007068 SewerSEWER CONNECTION PERMIT G((p-'Zca
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 from the date of issuance. No
extensions will be granted. f s - l l
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PROJECT INFORMATION lf/
Job address: Dry Line
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City: S»c4-q,/7p Gf 2
Zip:
Parcel number (irtarow ):
Owner's name:
City/State: 117ci��i(.16
Zip:
Phone: 9cP/r cr��
First-time contractors or home -owners performing the installation must first contact the utilities department (in person
or via phone [456-3604]) before a permit can be issued.
Name of Utilities Division person contacted:
CONTRACTOR INFORMATION
State contractor license number:
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Utilities installers permit number:
Contractor (company name):
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Business address:
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City/State: ;ca,Glq or
Zip: 97.7/P'.Phone:l/��i Pe"l/,d
INTERIOR PLUMBING ALTERATIONS? (yes/no) circle one
Fill out the information in the table below if applicable**
Contractor (if different from above): Phone:
Business Address:
City/State/Zip:
ohplumbrng reversal jee injormmtion see reverse -side oftkisfornr .
FEE INFORMATION
Sewer Connection: Number of Buildings 1 X (times) $50 (per bldg) = $
TOTAL FEE
* One permit required for each separate building, shop, garage, etc., that will be connected to the sewer.
* Condos, townhouses, & 2- 3- and 4-plexes require 1 permit per address/stub.
* Multiple buildings (apartments, industrial complexes) require 1 permit per building.
(For situations notfovered here, call the County, tilities Division (4)456-3604)
APPLICANT SIGNA
207G`= i Date: P5-97 576/
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Spokane County Division of Buildings
West 1026 Broadway Avenue * Spokane, Washington 99260
PHONE: (509) 456-3675 * FAX: (509) 324-3198 * TDD: (509) 324-3166
Spokane County does not discriminate on the basis of disability in the admission to, or treatment or employment in, its programs or activities.
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