1999, 11-08 Permit App: 99010815 Sewer) D 15 SEWER CONNECTION
County Division of Utilities
NNECTION PERMIT APPLICATION FORM
PLEASE NOTE: This application form must be filled out accuruely and in its entirety, and signed, or a permit will not be issued.
that sewer permits are valid for 12 months form the date of issuance. No extensions will be granted.
PROJECT INFORMATION
Also note
Job Address: // Z.
6,2,9c6
Parcel Number: Lot: Block:
/Regular
• Sewer
❑ Repair
❑ Addition
❑ Abandonment
CHECK APPLICABLE BOXES
Q Residential flew
O Commercial 0 New
O Temporary
Owner's name:
l eggy 42015 -Sol
Address: lit IL E 6/2i9"
City/State: ,lp n tit wU,
Zip: 9/2-0C
Phone: 6_5-0l) (27-8775
:t
FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMING THE INSTALLATION MUST FIRST CONTACT THE
UTILITIES DIVISION BEFORE PERMIT(S) CAN BE ISSUED.
SIGNATURE OF UTIL1I1ES DIVISION PERSON CONTACTED:
CONTRACTOR INFORMATION
Contractor (company name): //�/S
304c. -R DI it L' -'on Sate contractor license number:
�--7
Business address: i 11 2 Lt E No/Z14
City/State: <ino is / LA -7S Zip: 4ca o 6
Bo13
Contact Name: e'2042 U t frk v�
Phone Number:
Z3o-tali
INTERIOR PLUMBING ALTERATIONS? (yes/no) circle one
Fill out the information in the table below ifapplicable"
Contractor (if different from above): Phone:
Business Address: City/State/Zip
*"For plumbing reversal fee information, see reverse side ofthisform.
FEE INFORMATION
Number of Buildings connecting to sewer X (times) $100 (per bldg) _ $
• 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 lines) separate address and separate stub, one permit is equired per
address per stub;
• For a single building duplex, triplex or fourplex with single ownership, one permit ss required
• Multiple buildings (apartments, industrial complexes) with single ownership, one permit required per budding connecting to the sewer.
TOTAL FEE
(FOR SITUATION
APPLICANT SIGNATURE:
COVERED HERE, CALL THE COUNTY DIVISION OF UTILITIES AT 477-3604)
(J z
L.
DATE:
1-67
Method of Payment:
❑ Cash D Check
0 Visa
0 MasterCard 0 Discover Card
Date: Expires:
Bankcard Number:
Authorized Signature:
Spokane County Division of Building & Planning
1026 West Broadway Avenue * Spokane WA 99260
Tel. No (509) 477-3675 *Fax No. (509) 477-4703 * TDD No. (509) 324-3166