1998, 10-20 Permit App: 98010367 Sewer 4.
_ �� Spokane County IDiv cion of Utilities
(,► ,..,,c--)SEWER CONNECTION PERMIT 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 form the date of issuance. No extensions will be granted.
PROJECT INFORMATION
Job address: --h D Line Sewer? Owner's name:
City: City/State: 5 e-f'ei or<. c"'AJ
Zip: Zip: j`9`23
Parcel Number(if known): Phone: ,..,5-z3-5! 05-5-2-
First-time contractors or home-owners performing the installation must first contact the Utilities Division in person or via phone[456-3604JJ before a
permit can be issued.
•
Name of Utilities Division person contacte . 10 ."7.0 '1 Y
CONTRACTOR INFORMATION
Contractor(company name): Sate contractor license number:
Contact Name:
Business address:
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 thishrni.
FEE INFORMATION
Sewer Connection: Number of Buildings I X(times)$100(per bldg) = $ / 0 0 0 0
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 @ 456-3604)
APPLICANT SIGNATURE: '`�*--c".,.L� c L DATE: (-'C) 2 L', /9
Method of Payment:
Eli Cash ❑ Check 0 Visa 0 MasterCard 0 Discover Card
i
Date: Expires:
Bankcard Number:
Authorized Signature:
Spokane County Division of Building&Planning
1026 West Broadway Avenue ''Spokane WA 99260