2000, 01-31 Permit App: 00000575 SewerSpokane County Division of Utilities
SEWER CONNECTION I,ERMIT 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.
PROJECT INFORMATION
Job Address: 5 003 N. Lai-CALfROC--
Parcel Number: L116364
G36 4/.• III, 3 Lot: 13 Block:
CHECK APPLICABLE BOXES
`�J• Regular
❑ Dry Sewer
❑ Repair
❑ Addition
❑ Abandonment
Liik Residential O New
O Commercial 0 New
O Temporary
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Owner's name: A li` Teti'' 14,(9e/r �Rd
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Address: SOC7i N L(f l'(r-v R•
City/State: Spdl2I %r/4
Zip:
Qqd4
Phone:
89t--37 /S--
FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMING THE INSTALLATION MUST FIRST CONTACT THE
UTILITIES DIVISION BEFORE PERMIT(S) CAN BE ISSUED. LK ; O 15$Lta pearl T. SFG F0/2/n
SIGNATURE OF UTILITIES DIVISION PERSON CONTACTED: �C�/,� � Nbi&'JeO, C2—orC. �,�t.tx t.a>
CONTRACTOR INFORMATION U
Sate contractor license number:
Contractor (company name):
UNKNOGMN AT T!>'/S T///.'5
/ /0/7a"
Business address:
City/State: Zip:
Contact Name:
Phone Number:
WIL page egFQ6,0 INTERIOR PLUMBING ALTERATIONS) (esn / o) circle one
f if
Contractor (if different from above): Phone: »»
Fill out the information in the table below ifappylicable
Business Address: City/State/Zip
**For plumbing reversal fee information, see reverse side of this form.
FEE INFORMATION
Number of Buildings connecting to sewer / X (times) $100 (per bldg) _ $
TOTAL FEE
• 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 pennit 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)
--t APPLICANT SIGNATURE: 2cWW1 27 a
a DATE: 3/
%LL 6261
Method of Payment:
D 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) 477-7198 * TDD No. (509) 477-7133