1999, 12-01 Permit App: 99011994 Sewer spoxane county Lnvrsron or unnues
SEWER CONNECTION PERMIT APPLICATION FORM
PLEASE NOTE: This application form must be fillecrout 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. No extensions will be granted.
PROJECT INFORMATIONLl 6:1_ i (c� t C.
Job Address: f Z/Z 0 E 46 1Z
Owner's name: ! `Jin Ci- V
Parcel Number: Lot: Block:
Address: "X. /2 k
CHECK APPLICABLE BOXES //
Regular O Residential O New City/State: 4-,/ /tee,/
❑ Dry Sewer O Commercial O New ? L (L Cf'
❑ Repair O Temporary Zip: may(( � 2
❑ Addition Phone: 7 11 9%^� L�j 3 L(
❑ Abandonment
FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMING THE INSTALLATION MUST FIRST CONTACT THE
UTILITIES DIVISION BEFORE PERMIT(S)CAN BE ISSUED.
SIGNATURE OF UTILITIES DIVISION PERSON CONTACTED: C)K- res' S>�-`� `�l L 12. c'i'w 3 PL1Z.'li / 12.Z )'
f � n
CONTRACTOR INFORMATION (,J(
Contr c r(comp i a e): Sate contractor license number:
Business address: r Contact Name:
City/State: /� Q!tea w L!/' Zip:
Phone Number:
INTERIOR PLUMBING ALTERATIONS? (yes/no) circle one
Fill out the information in the table below if applicable**
Contractor(if different from above): Phone:
Business Address: City/State/Zip
**For plumbing reversal fee information,see reverse side of this form.
FEE INFORMATION
Number of Buildings connecting to sewer X(times)$100(per bldg) _ $
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 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)
APPLICANT SIGNATURE: DATE:
Method of Payment-
CI Cash Check D Visa D MasterCard D Discover Card
Date: Expires:
Bankcard Number:
Authorized Signature:
Spokane County Division of Building&Planning
1026 West Broadway Avenue*Spokane WA 99260
Tel.No.(509)477-3675*Fax No.(509)477-4703*TDD No.(509)324-3166