2004, 10-11 Permit App: 04007556 SewerSpokane County Division of Utilities tX D
SEWER CONNECTION PERMIT 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 form the date of issuance. No extensions will be granted. A separate right-of-way permit is
required for any worjC performed in or from the county right-of-way.
0 PROJECT INFORMATION
',l Job Address: go i Ll E Ma r
Owner's name: 1- Q E r–hen / ig n nP (-ie ,1 .Cu*
x Parcel Number: '-1 51 R.3 • o'?' -1 1 Lot: Block:
X Project Name: 1/J- 5prG'GIIP. €rwrrAddress: '301 C Ftr-1
arn5-fcn
x ULID Name: `J
"City/State: S { OVQAP Um dif y l l�
Zip: q q 212
'(Phone: 5oq– "'l al -A qS9
CHECK APPLICABLE BOXES
a Regular
❑ Dry Sewer
❑ Repair
❑ Addition
❑ Abandonment
BJ Residential 0 New
❑ Commercial 0 New
❑ Temporary
* FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMING THE INSTALLATION MUST FIRST CONTACT THE
UTILITIES DIVISION BEFORE PERMIT(S) CAN BE ISSUED.
SIGNATURE OF UTILITIES DIVISION PERSON CONTACTED:
Contractor (company name):
Sate contractor license number:
Business address:
City/State: Zip:
Contact Name:
Phone Number:
INTERIOR PLUMBING ALTERATIONS?
no)circleone CtTY ot- SPGKPrDr UAU,4Y
Fill out the information in the table below if applicable**
Contractor (if different from above): Phone:
Business Address: City/State/Zip
**For plumbing reversal fee information, see reverse side ofthis form.
FEE INFORMATION
Number of Buildings connecting to sewer X (times) $100 (per bldg) = $ + $10.00
RIGHT OF WAY PERMIT
• 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 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 required per building connecting to the sewer.
(FOR SITUATIONS NOT COVERED HERE, CALL THE COUNTY DIVISION OF UTILITIES AT 477-3604)
�( Is any of the work to be performed in or from the county right-of-way? 0 Yes
s �No
`). APPLICANT SIGNATURE: n p a c1-- ^^^ M l ta_Y_+
DATE: /O //—O 9
Method of Payment:
❑ Cash 0 Check
0 Visa
0 MasterCard 0 Discover Card
Date: Expires:
Bankcard Number:
Authorized Signature:
Spokane County Division of Buildmg & Code Enforcement
1026 West Broadway Avenue * Spokane WA 99260
Tel. No. (509) 477-3675 * Fax No. (509) 477-7198 * TDD No. (509) 477-7133 '