1997, 02-03 Permit App: 97000541 SewerSEWER CONNECTION PERMIT 9�,
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 from the date of issuance. No
extensions will be granted.
PROJECT INFORMATION�11�
Job address: Dry Line Owner's name:
City:.City/St
Zip: q 4 ,'--A n Co Zip:_
Parcel number(daaavv): I Phone:
I `t D (-I - (o'aI )
First-time contractors or home -owners performing the installation mustfirst contact the utilities department (in pi
or via phone [456-36041) before a permit can be issued.
Name of Utilities Division person contacted:
Contractor (company name):
State contractor license number:
Business address: Utilities installers permit number:
7,2>1 L,
(irnnclr.Jca.l
City/State:_ SP^pLe,nJta
Zip: 9 82.12 Phone: O C[ l - G 9r -W
INTERIOR PLUMBING ALTERATIONS?
Fill out the information in the table below ifaaolii
Contractor (if different from above):
P .. �1.nF Izm
Business Address:
InS2o E. (>
City/State/Zip:
C4rcu)arfr< WA 44p1f—
FEE INFORMATION
Sewer Connection: Number of Buildings �_ X(ti.)$50 err bids) =$�_� QO
TOTALFEE
• 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 addres&Wub.
• Multiple buildings (apartments, industrial complexes) require 1 permit per building.
(For situations not covered here, call the County Otilities Division @ 456-3604)
APPLICANT SIGNATURE:" Date:_.
• 90•a
Spokane County bivision 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 N the admission to, or treatment or employment in, Its Programs or activities.