1999, 02-06 Permit App: 99011607 Sewer Spokane County Division of Utilities
SEWER CONNECTION PERMIT APPLICATION FORM C-1(-'1 -1' 62 C 7
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. No extensions will be granted.
PROJECT INFORMATION
Job Address: I7'Z 1 Z £ 13-/-14 /4(--0"1— G 2
Owner's name:
Parcel Number: Lot: Block:
Address: /2-7/2- /31-4
CHECK APPLICABLE BOXES
❑ Regular X Residential ❑ New City/State: f kB'-'11t-
❑ Dry Sewer O Commercial D New g9 Z/&
Repair In Temporary Zip:
❑ AdditionPhone: 12 -9 7 7
U Abandonment
" FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMING THE INSTALLATION MUST FIRSTCONTACT THE
UTILITIES DIVISION BEFORE PERMIT(S)CAN BE ISSUED.0 T O 15,54A t- 5c� .vE.2 `, Q._�Ivii 02, 11v-ts ]
SIGNATURE OF UTILITIES DIVISION PERSON CONTACTED: LT`�'`� � Z'�' CZ t!
Al CONTRACTOR INFORMATION
Contract cony n. iiSate contractor license number:
Business address: Contact Name:
City/State: Zip:
Phone Number:
INTERIOR PLUMBING ALTERATIONS? (yes no circle one
Fill out the information in the table below if applicab
Contractor(if different from above): Phone:
Business Address: City/State/Zip
**For plumbing reversal fee information,see reverse side of this form.
FEE INFORMATION 0._.°Number of Buildings connecting to sewer I X(times)$100(per bldg) _ $ 10�
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:
O Cash 0 Check 0 Visa 0 MasterCard 0 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