2000, 03-29 Permit App: 00002197 Sewer 1 -. i
Spine County Division of Utilities ``-
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 arc valid for 12 months from the date of issuance. No extensions wilt be granted.
PROJECT INFORMATION
Job address: Dry Line Owner's name:
3 ILoOli S41.4ocv Sewer? (Y/N) HARLEY C. DOUGLASS INC.
City: le pc4,0 V li-J •o City/State: SPOKANE WASHIUGTQN
Zip: S q 20Zip: 99208
Parcel number(in nown): • . . 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. _ i
Name of Utilities Division person contacted: .L. _3•3O's O _
CONTRACTOR INFO 'til- TION
Contractor(company name): State contractor license number: .
CANNON EXCAVATING CANNO**102C1
Business address; Contact Name:
P.O. Box 28778
City/State: . Spokane Washington 99228-8778 .-
Zip: Phone; 509-467-6522 Phone:
INTERIOR PLUMBING ALTERATIONS? (yes/no)at*one
Fill out the information in the table below if applicable**
Contractor(if different from above): Phone:
Business Address: City/State/Zip:
I
':i�l.i'i �..... .....`'.K��r'> P...:.:.::a::�'I�C�l .4�-��°..Pt:�F:C•;...,, � '�4J> :-`� x ,F.1tt;Ye ,. ,R xasS���l. ��t@
FEE INFORMATION 00
Sewer Connection: Number of Buildings j X( )$100(pet WV _$ l 0 3
TOTAL FEE
• For a single-family residential unit,one permit is required
• For a condominium,townhouse,duplex,triplex or fourplex with separate ownership(as determined by tot lines)separate
address and separate stub,one permit is required per address per stub;
• For a single building duplex,triplex or fourplex nith 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•r •vered here,call the County Division of Utilities®4563604)
APPLICANT SIGNATURE: yr i Date: 7 Z ' 'O
Return to:
Spohwm Cool Ditaim of 8witaed&Ptanfriad
Was t026 BnadaryAram'S)obasor,W'ash6gtat 99260
PHONE:(509)456-3675 •FAX:(509)374-5198•TDD:(509)324.3166
Spokane Gena dee,set&,avow.es he hew o(dassInlmy is&e,dr.-moo a,or smarms R implet''e'^rill is Pepin,a l aieide► SSA vw.N...I,.....M