2004, 02-26 permit: 04000896 SewerSpokane County Division of Utilities
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: -N' o extensions will be granted. A separate right-of-way permit is required for any work
performed in or from the county right-of-way.
Job Address: (711 7 E
Parcel Number.
Project Name:
ULID Name:
PROJECT INFORMATION
Lot: Block:
s i 4)Z1
CHECK APPLICABLE BOXES
ti Regular
❑ Dry Sewer
❑ Repair
❑ Addition
U Abandonment
O New l�
❑ New) /
,i Residential
0 Commercial
0 Temporary
Owner's name: C
Address: 9o7-7 t 4 o7
City/State: 5i1A-4/b,-u"(
Zip: fZ/
Phone: —2--/v7
* FIRST TIME CONTRACTORS OR HOME OWNERS PERFOR]%IING THE INSTALLATION MUST FIRST CONTACT THE
UTILITIES DIVISION BEFORE PERMIT(S) CAN BE ISSUED.
SIGNATURE OF UTILITIES DIVISION PERSON CONTACTED:
Contractor (company name):
f
Business address: "7-r Z ( k i
City/State: 7/ )L117-7 4 Zip:
Sate contractor license number:
f &z.L.
Contact Name:
Phone Number: 2 5 / - c`)o ) c
INTERIOR PLUMBING ALTERATIONS?
Fill out the information in the table below if applira ee
o) circle one
Contractor (if different from above): Phone:
Jnr— 6C nAf,
Business Address: City/State/Zip
%%For nwersalfee information, see reverse side of this form.
FEE INFORMATION
Number of Buildings connecting to sewer / X (times) 5100 (per bldg) = S + 510.00 =
• For a sine -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, industnal 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-wav? 7 Yes O No
APPLICANT SIGNATURE:
RIG IIT OF \C.\Y PER\IIT
DA I L: 2 —26-- `'/
Method of Payment:
0 Cash
0 Check 0 Visa
0 MasterCard 0 Discover Card
Date: Expires:
Bankcard Number:
Authorized Signature:
Spokane County Division of Building & Code Enforcement
1026 West Broadway Avenue * Spokane WA 99260
Tel. No. (509) 477-3675 * Pas No. (509) 477-7198 * TDI) No. (509) 477-7133