2002, 06-18 Permit App: 02004866 SewerSpokane County Invision of Uritnes
SEWER CONNECTION PERMIT
APPLICATION FORM
?LEASE NOTE: This application form mist 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 from the date of issuance. No extensions will be granted.
PROJECT INFORMATION
Job address: 17 O 3
5 ,v .e-- -8-
City: V-era-JJw/e
Zip: ' 99037
Parcel number(akaew ):
City/State:
Zip:
Phone:
First-time contractors or home -owners performing the installation must first contact the utilities department (in person or via phone
(456-360.0 before a permit can be issued.
Name of Utilities Division person contacted:
CONTRACTOR INFORMATION
Contractor (company name):
RlcN44'OSO& ;-/ONES
Business address:
i°o box 25"941/
City/State: S Po RAN £ L✓A
Zip: 99 22 .Y Phone: 966 -- 5` 96 4
State contractor license number:
if/el-MA/1'o 9,781,,f
Contact Name:
cis -do . 1
Phone: 794'-2 g3 2 -
INTERIOR PLUMBING ALTERATIONS? (yes/no) circle..
Fill out the information in the table below if applicable'
Contractor (if different from above): Phone:
Business Address: City/State/Zip:
*.*Fo'rplumbtngrcversalfee:iiiArmution;-seexeverseside,afthujoriri. ..
FEE INFORMATION
Sewer Connection: Number of Buildings . X(tiaa) S100(perb1dg) = S
TOTAL FEE
• For a single-family residential unit, one permit is required;
• For a condominium, townhouse, duplex, triplex or fourptex 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 orfourplex 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: Date:
Retum to:
Spokane Canty Division of Building er Planning
West 1026 Broadway Avenue • Spak me, Washington 99260
PHONE (509) 456-3675 • FAX (509) 324-3198 • TDD (509) 324-3166
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