1996, 01-12 Permit App: 96000255 Sewer S ',WER CONNECTION PERMIT . 2 55
APPLICATION FOI.14I q Cod - 2 i
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
Line1Owis name:
Sewer?9) QL
, U
City: ud O/c)/4 City/State: jThr
Zip: eleizofZ
Zip: 9920A
Parcel number(if known): Phone:
First-time contractors or home-owners performing the installation must first contact the utilities department(in person
or via phone 1456-3604]) before a permit can be issued.
Name of Utilities Division person contacted:
CONTRACTOR INFORMATION
C tractor (company na e): State contractor license number:
t /� l�A/A/b fit /c2C/
siness address: Utilities installers permit number:
f-. o. - 28778
City/State: _ 4 kGwu.i
Zip: t' Phone: <f.6 7 - 1p x,22
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:
**For plumbing reversal fee information, see reverse side of this form.
FEE INFORMATION
Sewer Connection: Number of Buildings / X(times) $SO(per bldg) = $ 50
TOTAL FEE
*One permit required for each separate building, shop, garage, etc., that will be connected to the sewer.
*Condos, townhouses, & 2-3-and.1 plexes require 1 permit per address/stub.
*Multiple buildings(apartments, industrial complexes) require 1 permit per building.
(For situations not covered here, call the County Utilities Division®456-3604)
•
APPLICANT SIGNAT " � � .i ��� Date: / ' / 2 •�w
4444
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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