1995, 09-25 Permit App: 95007676 Sewer SEWER CONNECTION PERMIT Q5-5— c
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 from the date of issuance. No
extensions will be granted.
PROJECT INFORMATION
Job address: Dry Line Owner's name:
J„- 2 +0 6 Li d5, /` T/ Sewer? ( ' -.T i i i in
City: S Cil ,t w tb City/State: ,;p0/Le�'u-
Zip: (Ic •Z 0.6 Zip: 7 6
Parcel number(jntnown): Phone: 31/ - 6 3-6 7,
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: tet,
CONTRACTOR INFORMATION
Contractor(company name): State contractor license number:
0UnX‘-Ower
Business address: Utilities installers permit number:
City/State:
Zip: Phone:
INTERIOR PLUMBING ALTERATIONS? ( /no) rirc�e«K
Fill out the information in the table below if applica' *
Contractor(if different from above): Phone:
I-&/W6G/-i'/�E/L
Business Address: City/State/Zip:
a''m�° " �x #*For plumbing reversal y'ee lnformntl rn see reverse side of this Dorm ,
FEE INFORMATION
Sewer Connection: Number of Buildings J X(times)$50(per bldg) = $ TOT FEE
*One permit required for each separate building,shop,garage,etc.,that will be connected to the sewer.
*Condos,townhouses, &2-3-and 4-plexes require 1 permit per address/stub.
*Multiple buildings(apartments,industrial complexes)require 1 permit per building.
(For situations not covered here,call the Cou Utilities Division @ 456-3604)
APPLICANT SIGNA ' ". Ai(2 Date:
onotaiso)
Spokane County Division of Buildings
West 1026 Broadway Avenue * Spokane, Washington 99260
PHONE: (509)456-3675 * FAX: (509) 324-3198 *TDD: (509) 324-3166
Spokane County does not discriminate on the basis of disability in the admission to,or treatment or employment in,its programsoracti���