1996, 01-12 Permit App: 96000268 Sewer SF,WER CONNECTION PERMIT
APPLICATION FOI
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 Own is name:
/5—f7 . lo7 / Sewer?f//N) Q/ L C \ e) ."(ass
City:��'' J City/State: k't _a - Sr A
Zip: LX€2,qe, Zip: 99.2.0tiS
Parcel number(if known): Phone: q
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
C tractor (company n3 'e): State contractor license number:
C K (' 4 tZ/9 cAAGAtd /OZ-e-/
siness address: Utilities installers permit number:
2877E
City/State: _
Zip: t' __A; Phone: 7 - x,22--
INTERIOR PLUMBING ALTERATIONS? (yes/no) circlaone
Fill out the information in the table below if applicable**
Contractor (if different from above): Phone:
Business Address: City/State/Zip:
n. *w **.For plumbing reversal fee information, see reverse side of this form.
FEE INFORMATION
Sewer Connection: Number of Buildings I X(times) $SO(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 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 @ 156-360.1)
•
APPLICANT SIGNAT / � 4 �` k—also / .Luf Date: �a
44444/on lir
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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