2003, 03-27 Permit App: 03002061 Sewer?:Spokane,Countyaiivtslon of
SEWER CONNECTION PERMIT
APPLICATION FORM .
PLEASE NOTE: This application form must be filled out acAuately and in its eiitirety, and signed, or a permit will not be issued.
Also note that sewer permits are valid for 12 months from the date of issuance. -No extensions will be granted.
PROJECT INFORMATION
Job address' Dry Line
:,ii 5. mL J)OIU u) Sewer?
City: 0 KA'I v l
Zip: C7 (9‘01P
Parcel number comov.n):
Owner's name: /L/
7-a)6/ itiCerrax-/
City/State: SfRtr. , WA
Zip: (19 Zo t0
Phone: CSS) 92.4,-15/9
First-time contractors or homeowners performing the installation must first contact the utilities department (in person or via phone
[456-3604J) before a permit can be issued.
Name of Utilities Division person contacted:
CONTRACTOR INFORMATION
Contractor (company name):
-745 r✓L t ih4�i. ]C�
Business address:
/1070/ (%d-cA./EV A1 -'j'
City/State: (,a,a,e.oict . 60,4-
Zip:
ISAZip: 99437 Phone:&4'D9) 89/—/232 -
State contractor license number:
Fol --SOC ; 033 Da
Contact Name:
Phone: (609) 971-650Le
INTERIOR PLUMBING ALTERATIONS? (yes/no) drde ono
All out the information in the table below if applicable**
Contractor (if different from above): Phone:
Business Address:
City/State/Zip:
:.>.... ... ... ........ Fo"rPluitibing reversdbfeE'if+fbrmnhon,aeerrversrside:d thisjarinfi: r'
Sewer Connection: Number of Buildings
FEE INFORMATION
X(ti,,,cs) SIN (bldg) _ $ /®O
TOTAL FEE
• For a single-family residential unit, one permit is renuired;
•• 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 @ 456-3604)
APPLICANT SIGNATURE:
DT2VID NERQE
Date: dp 7 03
Rea m m:
Spokane County Division of Building er Planning
Ir cif 1026 Broadway Accrue `Spokane, Wacbingten 99260
PHONE (509) 456-3675 • FAX (509) 324-3198 TDD: (509) 324-3166
Spak.w County doe not daannnas an ehe bas ofd,obihK u the . mmoa 03. of vne ent or employment w w p.eg.m n sena