2002, 06-03 Permit App: 02004326 Sewer Spokane County Division of Utilities � 4A' � ��
SEWER CGTNECTION 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
(C.Job Address: I 09 ) t2e2— /0 702-0 SPrt^1/'tc 6j
Owner's name: D 0 r4 b y Z o y
Parcel Number: Lot: Block:
Project Name: Address: i ) ? - 5 prih1 t t t 14
ULID Name:
City/State: 'POk' 0.'"t (,.J A +-
CHECK APPLICABLE BOXES
,IkRegular ❑ Residential 0 New Zip.
U Dry Sewer 0 Commercial 0 New
Phone:
U Repair 0 Temporary
❑ Addition
❑ Abandonment
* 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:
Contractor(companyame): s Sate contractor license number:
S-Pe .ek14' :-4 We 59e.c �. Woi �mS'
c_
Business address: Q l 6r .• Conta Name:
i itis. iv\a `W\
City/State:(2_Qt� '.�D. Zip:`d Ja !$� �•["�-)-64—Oct
/L
Phone Number: l. )' O l(o
INTERIOR PLUMBING ALTERATIONS? (yes/no) circle one
Fill out the information in the table below if applicable"-
Contractor
pplicable*eContractor(if different from above): Phone:
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)S100(per bldg)=S + S10.00=
RIGI I i 01'\\-.\l PI:R\lI I
• Pot 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 permit is required per address per stub.
• Por a single building duplex,triplex or Fourples with single ownership,one permit is required
• Multiple buildings(apartments,industrial complexes)with single ownership,one permit required per budding 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 . r from the county ight-of-way_? 0 Yes No
APPLICANT SIGNATURE: 1/14"/ • 1��� DATE:
Method of Payment:
O Cash 0 Check 0 Visa 0 MasterCard 0 Discover Card
Date: Expires:
Bankcard Number:
Authorized Signature: