2002, 03-19 Permit App: 02001841 Sewer • Spokane.Coun
tyLivision_o i es
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 from the date of issuance. 'No extensions will be granted. -
Y... PROJECT INFORMATION
Job address: Dry Line Owner's name: /
y�/^, , \ j Sewer? p iii -7- j 77�,n E-5, /ti -•
City: Q kA(V E City/State: 5R:3,e: - i GOA
Zip: ay, Zip: q9'
Parcel number(ifx,own): Phone: - 4...—/5/9
924-J5/9
L15 Ciqc9
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(company name): State contractor license number:
7k FoLSOG ; 0 33 7Dik
Business address: Contact Name:
/62 7.!)./
City/State: ('E,�H1 - G
Zip: 99a3'J Phone:e5 ) 8 9/—/Z3Z Phone: (6 09) 9.7--(e.ODZ
INTERIOR PLUMBING ALTERATIONS? (yes/no) dick.
_ Nll out the information in the table below if applicable**
Contractor(if different from above): Phone:
Business Address: City/State/Zip:
.. ::::::... ..
*#For.plumbing reixersat•ee mformahonr see res erse side of thus farm. ;s:::;:
- FEE INFORMATION
Sewer Connection: Number of Buildings / X(tin )$100(par bldg) = $ /00
TOTAL FEE
• For a single-family residential unit,one permit is required;
y 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 coibtplexes)with single ownership,one permit required per building connecting to
the sewer.
(For situations not vered here,call the County Division of Utilities @ 456-3604)
` î APPLICT SIGNATE: Date: I
Return to:
Spokane County Division ofBxildng dam'Planning
West 1026 Broadway Avenue*Spokane, Washington 99260
PHONE:(509)456-3675 *FAX(509)324-3198*TDD:(509)324-3166
Spotsne County does not dtsat,onote on the bans of dttabtbts m the sdtmmon to.of treatment of employment O its psogm a.ca.itiea "`�'"