1994, 10-27 Permit App: 94010741 Sewer SEWER CONNECTION PERMIT
APPLICATION FORM qr141
PLEASE NOTE: This application form must be filled out accurately and in its entirety, and signed,
or a permit will not be issued. Also mote that sewer permits are valid for 12 months from the date
of issuance. No extensions will be granted.
PROJECT INFORMATION
Job address: Diy Lines Owner's name:
S �. :.y ) LL
�yo3 S, ���nwN Sewer.� : � ;ate (✓ _
City: Spo )c xN e \U A- City/State: S�(�
Zip: To-06 Zip: 'Th-0
Parcel number (if known): Phone:
cod – � 11-1 h.? 4
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 Department person contacted:
CONTRACTOR INFORMATION
Contractor (company name): State contractor license number:
436L LONG/ Gxc_nvA; N9
Business address: `` /� Utilities installers permit number:
S,91-ti S 5A-A. /-t
City/State: VA L\ / -r.)1- 3_ kkJ A
Zip: 9` 0,. e Phone: S b9 -
INTERIOR PLUMBING ALTERATIONS (if applicable)** �d/v�
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 , X (times) $50 (per bldg _ $ -0 •0'0
TOTAL FEE
* One permit required for each separate building, shop,garage, etc., that will be connected to the sewer.
* Condos, townhouses, &2- 3- and 4-plea-require I permit per address/stub.
*Multiple buildings (apartments, industrial completes) require 1 permit per building.
(For situations not covered here, call the County Utilities Division @ 456-3604)
APPLICANT SIGNATURE: C/A__4( Date: 0 d 27 16 5L(
.4.444.03
Spokane County Division of Buildings
West 1026 Broadway Avenue * Spokane, Washington 99260 * (509) 456-3675