2003, 05-19 Permit App: 03003763 Sewer Spokane County Division of Utilities
SEWER CONNECTION PERMIT APPLICATION FORM
NO l'l:: This application form must be tilled out accurately and in its entirety,and signed,or a permit will not be issued. .\Iso note that sewer permits arc
aid for 12 months form the date of issuance. No extensions will be granted. A separate right-of-way permit is required for any work performed in or from
le county right-of-way.
,'a L-4� PROJECT INFORMATION
Address: 7/'T 57'11 de---7
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Owner's name: J�i,nry ��Ot�.�►
'arcel Number: � ��'� Block: /
'roject Name: .!- c Address: 6. 7/ 9
1.11) Name:
City/State: 4 2 4
CHECK APPLICABLE BOXES
dr-Regular Residential "New Zip: ��-
3 Ivry Sewer 0 Commercial 0 New 9�� — 6/F-9
phone:
3 Repair 0 'temporary
3 Addition
3 .\bandonmcnt
FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMING THE INSTALLATION MUST FIRST CONTACT THE
UTILITIES DIVISION BEFORE PERMIT(S)CAN BE ISSUED.
SIGNATURE OF UTILI'T'IES DIVISION Pl?.RSON CONTACTED:
Tontractor(company name): Sate contractor license number:
E • A4(. .4_2 E 9 99
iusmcss address: E. /o 7 O 7 /5"— Contact Name:
:iry/State: � �.�.., .1/ Zip: ?'lfa2 o6 401 /4��.'^J
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Phone Number: $'O' —../6" — a 6. 7/
INTERIOR PLUMBING ALTERATIONS? 4,417 ' o) circle one
Fill ond ilie informatioii in the table below if applicable**
•
Contractor(if different frail above): Phone:
.—
Business Address: City/State/Zip
**For plambi»g reversal fee information,see reverse side of this form.
FEE INFORMATION
Number of Buildings connecting to sewer / N (times)S100(per bldg) =S/CO. `+ S10.00= 400• oo,
MCI l l-I'OF K.11 I'l..K XI VI
• I or a smdle-fam,1 rrsidenual unit,ane permit is requureJ;
• I or a condominnun,townhouse,duplex,triplex or fnurples with separate ownership(as determined bt Int lines)separate address and separate srub,one permit is required per address per srub;
• for a singic building duplex,triplex or fnurples with single ownership,nnc permit is required
• Nltiltiplc buuiduse:(aparnnents,industrial enmpleses)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 or from the county right-of-way? Q EI'cs 0 No
\I'PI.IC.\NI'SIGN.\'TURI•:: 9yL 1J:\'I'I:: / 1-03
Method of Payment: ��
❑ CashCheck 0 Visa 0 MasterCard 0 Discover Card
Date: I?spires:
liankcard Number:
\urhorized Signature:
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