1997, 06-03 Permit App: 97003756 SewerP:WER CONNECTION PERMIT
APPLICATION FOL.M
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 from the date of issuance. No
extensions will be granted.
PROJECT INFORMATION
Job address:
182-1 s Soy) ovock
City: locwmoI G"
Zip: 990Rb
Parcel number (irknown):
Dry Line Own is name:
Sewer? (Y/N) a, ---L - \- U
City/State: tach P G A
Zip: Q9.2 9tc;
Phone: .(7_9792___,
First-time contractors or home -owners performing the installation must first contact the utilities department (in person
or via phone [456-3604]) before a permit can be issued.
Name of Utilities Division person contacted:
CONTRACTOR INFORMATION
CC� t��ryyac'�tor (company na e):
siness address:
State contractor license number:
G
1;i1/4/o4k10 )dz el
O. Z-tr 2877f
City/State: d D k0 ,,cre_ /J'
Zip: t i Phone:o % — 1p,Z�
Utilities installers permit number:
INTERIOR PLUMBING ALTERATIONS? (yes/no) circle one
Fill out the infornration in the table below if applicable**
Contractor (if different from above): Phone:
Business Address:
City/State/Zip:
** For plumbing reversal fee information, see reverse side of this form.
FEE INFORMATION
Sewer Connection: Number of Buildings t X (times) $50 (Per bldg) = $
TOTAL FEE
* One permit required for each separate building, shop, garage, etc., that will be connected to the sewer.
* Condos, townhouses, & 2- 3- and 4piexes require 1 permit per address/ sub.
* Multiple buildings (apartments, industrial complexes) require 1 permit per building.
(For situutio of covered here, call the County Utilities Division ® 456-360.1)
APPLICANT SIGNATURE
Spokane County Division of Buildings
West 126 Broadway Avenue * Spokane, Washington 99260
PHONE: (509) 456-3675 * FAX: (509) 324-3198 * TDD: (509) 324-3166
Date:
Spokane County does not discriminate on the basis of disability to the admission to, or treatment or employment in, Its programs or activities.
V %c\.,,nrvdWnevik