1997, 01-30 Permit App: 97000504 Sewer 9' SEWER CONNECTION PERMIT
APPLICATION FORM
PLEASE NO is 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:
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City:
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Zip: 3 V--'_ Zip: r 3
Parcel number(if known): Phone:
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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
Contractor(c pany na e):. State wiAractor lice se number: ^D
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Busin e s, ,�_re�s 74 // Utilities installers permit number:
City/State: ()h 4 4/& /til .
Zip: , ' Phone: '-W '►_ ,
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:
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FEE INFORMATION -
Sewer Connection: Number of Buildings X(times) $50(per bldg) = $ f 64 d 6
/1 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-plexes require 1 permit per address/stub.
*Multiple buildings(apartments, industrial complexes)require 1 permit per building.
(For situations not covered here,out* Utilities I ivision @ 456-3604)
APPLICANT SIGNATURE: r / v.J Date: //PA 7
.3403443,
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 programs or activities.
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