2003, 03-05 Permit App: 04000798 Sewer Spokane County Division of Utilities ) r i7 f S
SEWER CONNECTION PERMIT APPLICATION FORM
PI F.ASE 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. A separate right-of-way permit is required for any work
performed in or from the county right-of-way.
PROJECT INFORMATION ecia3 eA
Job Address:
,�O�--^' Owner's name: /// ,'"7/4 ,4- /r
7
Parcel Number: ��7"t) ` C'GiLLot: Block: r/ /'
Project Name: l _ C Address: C7 /6// 3 � t t S
ULID Name: '—C/-''f
City/State:
CHECK APPLICABLE BOXES
Regular O Residential O New Zip:
U Dry Sewer CI Commercial O New S�j
Phone: ` ,�C6"
❑ Repair O Temporary (<
❑ Addition
❑ Abandonment
* FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMING THE INSTALLATION MUST FIRST CONTACT THE
UTILITIES DIVISION BEFORE PERMIT(S)CAN BE ISSUED.
SIGNATURE OF UTILITIES DIVISION PERSON CONTACTED:
Contractor(company name): Sate contractor license number:
Business address: Contact Name:
City/State: Zip:
Phone Number:
INTERIOR PLUMBING ALTERATIONS? (yes/1) .-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 information;see reverse ride ofthis form.
FEE INFORMATION
Number of Buildings connecting to sewer X(times)S100(per bldg)=S + $10.00=
RIGHT OF W:VV PERMIT
• 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 NOT COVERED HERE,CALL THE COUNTY DIVISION OF UTILITIES AT 477-3604)
Is any of the work to be performed in or from the cou ty right-of-way? 0 Yes No
APPLICANT SIGNATURE: s1 L/I /..e7/"..e DATE: /7%2/
Method of Payment:
13 Cash 13 Check 13 Visa 13 MasterCard 13 Discover Card
Date: Expires:
Bankcard Number:
Authorized Signature:
Spokane County Division of Building&Code Enforcement
1026 West Broadway Avenue*Spokane WA 99260
Tel.No.(509)477-3675*Fax No.(509)477-7198*7DD No.(509)477-7133