2002, 03-26 Permit App: 02001918 Sewera_ /eci7 Spokane CouniiDiviiion oft tilities:
SEWER CONNECTION FERMI' APPLICATION FORM .— -
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PLEASE NOTE This application form must be filled out accurat4aud in au entirety, and signed, or a permit will not be issued._ Also note
that sewer permits are valid for 12 months furm the date otissuance4sIo-extension/Will begranted. A separate right-of-way permit is
I required for any work performed in or from the county right-of:way. •
PROJECT INFORMATION
Job Address: C.7 e-0 NI •HerU--
.faWileilliame: Ire- V tiy et -Z
parcemunber:45(14. Z 514 ).ce ---41^42"
Projea Name: ALL E.Y is Tit Address. 3 Al, 71-4- v cv
Nj cii Regular CHECIC AMICAI3LE BOXES d/ Residential . 0 New ...... Zip
X7-
,
O Dry Sewer ' 0 Commercial ' :0 New
.0 Repair 4 - .. `.'..- 0 „TernporarY •• • - '
- ----- -0 Addition - ° ......,,.......
0 Abandonment - - - -- - - -
72;7:'7
...ur 14 isrPyso t ,
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ATioN
UTILITIES DIVISION BEFORE PERMIT(S) CAN BEISSUED...4 r71.44'12 ; COASIAL:7 *LE. iOtErleol)
;* FIRST TIME CONTRACTORS OKTIONTE OWNERSPERFORMINGIFIE/NSTALL- MUST FIRST CONTACT:THE ;
SIGNATURE OF UTILITIES DIVISION PERSON CONTACI 4111110 "9: "4' "
•
Contractor (company name):
.e.014..SN
Business address:
City/State:
tp:
-Sate contractor license number : ,
Contact Name:
Phone Number:. -
•
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INTERIOR PLUMBING_ ALTERATIONS? no) circle one
Fill out the information in the table below t a7p ** ..
Contractor (if different from above) Ith21P,412not...x6411.e '''8:
r----iMsef.
llamteL74&r,
Business Address: :• • ; i : ,439,000q .Rnts.P.111z .4.a , , . i
i ;...4%,i(x.r;IICity/State/Zip :::.•:- , -,
...
.i.).14,7,, .A.LiAai :.“. t., •i - , •
"For plumbing reversal fee information,. seereverse 'side ofthis form.
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v• ' - --*-', - '1;-' - --1- FORIVIATION5:717;-64,q Pa:. 1 " ' •
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Number of Buildings connecting to sewer: - I i ,- - - X (tames) $10r0 (per bld ii -S 74"ft`1.601, , ' • +.4
. ..„
• For a sioy,laamiliresiclential unit, one permit z,! required; i
• , For a condominiuM) townhouse, duplex; triplex or fourplex with separate ownership (as dettmined by lot lines) separate address and separate stub, one permit is required pc
address per stubi ;
2
, ....; ,... 7 , $ • 1 : T ? 4
• For a single building duplex,'triplex or fourplex with single ownership, one permit is required
• Muhiple buildinp (apartments, industrial convinces) with single ovrnership, one permit required per building connecting to the sewer.
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(FOR SITUATIONS NOT COVERED HERE, CALL THE CO jp DIVISION OF UTILITIES AT 177-3604)
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Is any of the work to be performed n or from the county rig h f-Wa
APPLICANT SIGNATURE:
DATE: 3 -
Method of Payment: •
0 Cash 0 Check 0 Visa • MasterCard 0 Discover Car
Date: Expires:
^ ^
Bankcard Number:
Authorized Signature: • • , ,:r. ok,
' Spokane COunty Division of u g orcement
1026 West Broadway Avenue * Spokane WA 99260
Tel. No. (509) 477-3675 * Fax No. (509) 477-7198 * TDD No. ) 477-7133