1996, 10-03 Permit App: 96007426 Sewer SEWER CONNECTION PERMIT r ` '
APPLICATION FORM a 11,5 , (;►
PLEASE NOTE: This application form must be filled out accurately and in its entirety, and signed,l`ir 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
Job address: Dry Line Owner's name:
f / o y/? /�/ T/� Sewer? (YIN)
City: 74T,f-/,,C-j, /,J fi - City/State: ;,./' ,eJ
Zip: Zip:
Parcel number(fknown): Phone: l 7 _ -7 7
First-time contractors or home-owners performing the installation must first contact the utilities department(in person
or via phone[456-3604]) before a permit can be issued.
Name of Utilities Division person contacted:
CONTRACTOR INFORMATION
Contractor(company name): State contractor license number:
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Business address: Utilities installers permit number:
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City/State:
Zip: 7 2_/ Phone: y%
INTERIOR PLUMBING ALTERATIONS? (yes/ : circle one
Fill out the information in the table below if applicable**
Contractor(if different from above): Phone:
Business Address: City/State/Zip:
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FEE INFORMATION
Sewer Connection: Number of Buildings X(times) $SO(per bldg) = $
TOTAL FEE
*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 I permit per address/stub.
*Multiple buildings(apartments, industrial complexes)require I permit per building.
(For situations not cyal here, call the County Utilities Division @ 456-3604)
t,rAPPLICANT SIGNATURE: _ /r Date: /,r' -
f noes
Spokane County Division 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 in the admission to,or treatment or employment in,its programs or activities.
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