2002, 04-23 Permit App: 02002868 Sewer Spokane 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 are valid for 12 months form the date of issuance. Ao extensions will be granted. A separate right-of-way permit is
required for any work performed in or from the county right-of-way. ?'&
PROJECT INFORMATION /1 , ',?)'
Job Address: 3 1C�
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Owner's name: n / ita--( -t'i
Parcel Number:35 Z 4- °4#611.c_Lon---- Bleck: _
Project Nam o raw N Address: C. y 5 .a
i TT®e:
I City/State: � c
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CHECK APPLICABLE BOXES
9 Reeular ...*"...'4d Residential 0 New Zip: qv, ?
❑ D Sewer.) 0 Commercial 0 New >2.-.❑ Repair 0 Temporary Pho : �>JS �;�{Y ;
❑ Addition
O Abandonment ,
* FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMING THE INSTALLATION MUST FIRST CONTACT THE
UTILITIES DIVISION BEFORE PERMIT(S)CAN BE ISSUED. $--1 •O1-. T O l .5-1-1. .. -,6,L.1N6-raiz./n,Ts
SIGNATURE OF UTILITIES DIVISION PERSON CONTACTED: ---k:C.:::12-.„, / Z�J/ 0-.
Contractor(company name): Sate contractor license number: /
>rx,-ar�n-c7'
Business address: Contact Name:
City/State: Zip:
Phone Number:
INTERIOR PLUMBING ALTERATIONS?(ye no) ircle one
Fill out the information in the table below ifapplica.
Contractor(if different from above): Phone:
Business Address: City/State/Zip
**For plumbing reversal fee information,see reverse side of this form.
FEE INFORMATION -dd
Number of Buildings connecting to sewer t X(times)$100(per bldg) o $ 1 00 + $1
// RIGHT OF WAY PERMIT
• For a single-family residential unit,one permit is required;
• For a condominium,townhouse,duplex,triplex or fourplex with separate ownership(as determined by lot lines)separate address and separate stub,one permit is required per
address per stub;
• For a single building duplex,triplex or fourplex with 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 NOT COVERED HERE,CALL THE COUNTY DIVISION OF UTILITIES AT 477-3604)
Is any of the work to be performed in orf m the county ri -of-way? 0 Yes ,"
APPLICANT SIGNATURE: No
\` 7�/' -- r —z--J --7-.)C�-'2 /--'� ) DATE: � ....7..,/:"
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Method of Payment:
0 Cash 0 Check 0 Visa 0 MasterCard 0 Discover Card
Date: Expires:
Bankcard Number:
Authorized Signature:
Spokane County Division of Building&Code Enforcement
1026 West Broadway Avenue*Spokane WA 99260
Tel.No.(509)477-3675*Fax No.(509)477-7198*TDD No.(509)477-7133