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1999, 11-08 Permit App: 99010817 Sewer
Spokane County Division of Utilities SEWER 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. /b /? PROJECT INFORMATION Job Address: X030 3 �l�j�j Owner's name: 6/2 "-/ Parcel Number: `�' / t `- C (Lot. Block: ` Address: /0 30 3 E 1��t ` ` e CHECK APPLICABLE BOXES 0/Regular residential l ew City/State: SPc f ( uC: 1114CDry Sewer D Commercial O New q1 ql2©6 ❑ Repair D Tem orary Zip: CI Addition // / Phone: (5-0`1 ) Z I -6 7 s 7 ❑ Abandonment ( l * FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMING THE INSTALLATION MUST FIRST CONTACT THE UTILITIES DIVISION BEFORE PERMITS)CAN BE ISSUED. o p T .L SIGNATURE OF UTILI 11bS DMSION PERSON CONTACTED: /1— 8 - q CONTRACTOR INFORMATION Contractor(company name): 5 (3013(s b"4"/ KS Sate contractor license number: c ISO T3 D (v Z Z Vy Business address: it 7 2 t/ E /VORA Contact Name: Lb r City/State: Sic k',, t c j Gf Zip: 911120 G °�j U 1/�Y Phone Number: 2 30_y 2 %J INTERIOR PLUMBING ALTERATIONS? (yes/no) circle one Fill out the information 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 / �y Number of Buildings connecting to sewer r X(times)$100(per bldg) = $ I C...1(---J TOTAL FEE • For 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; • 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 COVERED HERE,CALL THE COUNTY DIVISION OF UTILITIES AT 477.36604) APPLICANT SIGNATURE: 6;) L I DATE: /c/D7l�J j Method of Payment: D Cash D Check 0 Visa 0 MasterCard 0 Discover Card Date: Expires: Bankcard Number: Authorized Signature: Spokane County Division of Building&Planning 1026 West Broadway Avenue*Spokane WA 99260 Tel.No.(509)477-3675*Fax No.(509)477-4703*TDD No.(509)324-3166