1996, 09-05 Permit App: 96007420 Sewer 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.
PROJECT INFORMATION
Job address: Dry Line _.i Owner's name;
19, S \ U Sewer? (I'�/N)) ) . �'�rv� &L
City: City/State:
Zip: — Zip:
1 .< ;
Parcel number(irknown): •
Phone:
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:
Business dress: Utilities installers permit number:
Ci /State: S -) c f�
Zip:0E1 ' ( (a Phone: Of g-,`"") (',
INTERIOR PLUMBING ALTERATIONS? (yesno) le one
Fill out the information in the table below if applicable**
Contractor(if different from above): Phone:
Business Address: City/State/Zip:
""";^i u �"�� "�,+t Forptumb'ro reverse l fee informatlo ,see reverse side ofihisforrn
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FEE INFORMATION �
Sewer Connection: Number of Buildings / X(times) $50(per bldg) = $ (�' ,
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 I permit per address/stub.
*Multiple buildings(apartments, industrial complexes)require 1 permit per building.
(For situations not covered here, call the Co my Utilities Division @ 456-3604)
APPLICANT SIGNATURE: 'u' Ii. _ / Date: '/
.3.11010002
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. pfk