1994, 10-27 Permit App: 94010739 Sewer SEWER CONNECTION PERMIT
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APPLICATION FORM qt-i5 2-CA
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: Dry Line Owner's name:
S t- Sewer? (Y/N) (9 "k 2:111z--re AA1i)Z'R A/
City: 5�� %s✓G 7,//Y r City/State: 5'�2////vim=, 2c,//y
Zip: 2 2 Zip: Ci 9"2
Parcel number (if known): GlQ+424 f" Phone:
Ler -'SCK I - 36e, , 7 y 3 _ � � �57° 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 Department person contacted:
CONTRACTOR INFORMATION
Contractor (company name): State contractor license number:
1zb77L 3 t Liz 6Tc e&
Business address: Utilities installers permit number:
)pj3 e _ zap \f/( 5
City/State: N► 'e e_rv.16-t VJ6,4
Zip: a 8b'3 Phone: „Iq '1 e37
-515 -
INTERIOR PLUMBING ALTERATIONS (if applicable)**
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 bids _ �,
( TOTAL FEE,
* One permit required for each separate building, shop,garage, etc., that will be connected to the sewer. N1
* Condos, townhouses, &2- 3- and 4-plex require 1 permit per address/stub.
* Multiple buildings (apartments, industrial complexes) require I permit per building. ���
(For situations not covered here, call the County Utilities Division C-U 456-3604)
APPLICANT SIGNATURE: ,,a666.f/7 Date: /6 /2 , 1��/
3.0.14104.
Spokane County Division of Buildings
West 1026 Broadway Avenue * Spokane, Washington 99260 * (509) 456-3675
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