2006, 09-29 Permit App: 06006966 Sewerrlll'+I
r I CUL U J/ v u I .. IVU,VGA,+UVL Uc.7
Spokane County Division of kl!ilr'ti_ts 477-- 3641-'
SEWER CONNECTION ?Ertmr ' A?FLICJI iiON'FORM
O 1'! kAtili NOTE! '( hk finnlir,itirrn farm must Ir filled rut neruratcly anal rn its emir oriel seinntKl or 9 permit well not be ixxued Sewer ocrrrtits are valid for 12
months form the date of i>suance. A separate right -of --way permit is required for any work perforated in nr &nm the pablic right.of way. a interior
rlun,hing And electrical wr,r4 reiri;rex acmrtt• ;u•r•rit+,
it;[r .address: E
Parcel Number: 1,0 :
Project Name: � � r i1 D
t!] .ID Name:
^QFTSECT ; rNFOR* AIrION
ck'
Mrtcr',nanc: -��r 1Q C +moi
dret:z _ t- . r 5
CHECK APPLICABLE SORES
D Regular I 'r p _' to ~_t D _ f Zip-
CHECK
O Dry Sewer t^-„ nc ia. J,
0 Rcpair O `l'cmporarp
O Addition
bandorurient '
Id—C1
* FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMING THE INSTALLATION M1dST FIRST CONTACT THE
UTILITIES DIVISION BEFORE PERMIT(S) CAN BE ISSUED.
SJCNATIJRI:OF UJ71.IT11 .S DIVIS]ON PERSON CON' AC•Ji):
Contrac-tor (company name):
t'tee\ C
e6-4/ 9y7-Z;L 29"/P
c contractor I• eri e number
"ERSCU d
Businexa addrers: ?il 1(i L•.91 C+z l'Y1-
(pity/:tate:1Rr3SCi`i0� 1AIGSh lip: CM11 0
Contact Name.
Haut"'C'
Phony Numbtr. 5cet 99 3 _5,Dtt7
INTERIOR PLUMBING ALTERATIONS? (yea/no) circle one
Fill oar rbr infr malion in the roar bras if a#/renblr"
3 County 0 City of Spok•. r Valley
Contractor (if different from above).
ove).
iivaiue ,1 dklretke
Photo_
City/Stair/Zip
For
reversal ria iw
OR. IN num si& . 1Jlri
Number of 13uilddngs connecting to f;cwcr
• or a sin4ie•famiv resiJenty) unit, one wing is requited;
• for a condtmsinion. townhouse. dupleu. triplex or rottrpit wit) separate ouinesshtp (as determined by let lines) separate address and warm club, one permitis intoned pry addrres per sou
• Ekor a single building duplex, triples or fomplet with *tilde o-nnr)ip, one peanut is dequirm
• Mdrpile buildirup (mammary,irtdustrial complexes) aid, tangle owes sh;p, one pans:$ retained per hiking connecting to the serer.
(FOR S]TUATJONS NOT COVERED HERE, CAU. THE COUNTY DIVISION OF I.FT1LIT1ES A'1 4774 604)
Is any of the work to be performed in or from the public right-of-way? 0 Yes 0 No
Sbunly 0 City of Spokane Valley
APPLICANT SIGNATURI ii;; 42 s t ,/-- t)ATE•
Owner or Contractor (circle nor)
FEE INFORMATION
X (times) 5100 (per bldg = S + $10.0(1=
ANE COUNTY
RIGIir nAv PERMIT
Method of Pay ent:
Q Cash
is V to
:7 c.?3ra:+-rr: 7 Lrae.4v C ,
Dare„ _ - Expucs-
Bankcard Number
Authorized Signature:
tirnk snr !:ountc Dtpartmcnr of Huikling and Planning
lift West 13roadwa}• .1venue •' Spukanc W;1 99260
rel. No. (Si/9) 177-375' Fav Nil. (Stn 477-719V 1D) No. (51.19) 477-7133
T£12- Pkvj l S R ELEhSEo FOR Ce2A) ,)FCriDA)
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noose / f4ta,N DC7 N � f) S. S TEM r4 -/V .1> ?ii -Lc - h rs ' 9 q Ifo
IN A-0 imA) CE ?K- W S PEc_75 L) -B P 2 Co vg -gin ') sEPTi
-r-A ,4N)) !- 1)S (C)AJ11IF7T/Dn) 'T4 i- >S Nei Don)E SrSrer ULtt Nc7,U lU; DJh-1)
I ac01h-LLA-TOA./ t
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Tu
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Do Not CONNECT" Nz[)
A— MIS S iII M E