2002, 11-14 Permit App: 02010221 SewerSEWER 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 work performed in or from the county right-of-way.
PROJECT INFORMATION
Job Address: l Z-Zek- N. MAYr L),6.!- t��%
Parcel Number: 45 ($ l - D'� 8 • pd j�:
Project Name: k. -1u ltLln t rte%)
CHECK APPLICABLE BOXES
Regular
❑ Dry Sewer
❑ Repair
O Addition
O Abandonment
Residential ❑ New
11 Commercial 0 New
0 Temporary
Owner's name:
Address:
6;12-rczz1
/z_,2 c/
/1-(,„t/e6.--2(e/7-
City/State: s' -'i � (A---)71
/ 2. -
Phone: 5 �� %y�j — V3 7
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:C_.0
Contractor (company name):
Sate contractor license number:
Business address:
City/State:. Zip:
Contact Name:
Phone Number:
INTERIOR PLUMBING ALTERATIONS
Fill out the information in the table below ifa 1
o) circle one
Contractor (if different from above): Phone:
O LJr.tej
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) = $ + $10.00 =
For a single-family residential unit, one permit is required;
RIGHT OF WAY PERMIT
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 r fro
the county right-of-way? 0 Yes 0 No 1
> APPLICANT SIGNATURE: DATE: /! `'� "7
Method of Payment:
O Cash 0 Check
Date:
0 Visa
0 MasterCard 0 Discover Card
Expires:
Bankcard Number:
Authorized Signature:
Spokane County Division of Building & Code Enforcement
1026 West Broadway Avenue * Spokane WA 99260
Tel. No. (509) 477-3675 * Fax No. (509) 477-7198 * TDD No. (509) 477-7133