1994, 10-27 Permit App: 94010752 Sewer ui .P`d SEWER CONNECTION PERMIT 9q,(0-1 Sa
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 mote 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:
lot 0-7 C. ISS- Sewer? (Y/N) (� c-04e,15)
City: Seoy.6.. City/State: Qpm
Zip: Zip: el‘t 1 -
Parcel number (if known): Phone:
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 Department 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: -aQO . - w
Zip: 1 -1 Phone: C/ - Co2`-tL
INTERIOR PLUMBING ALTERATIONS (if applicable)**
Contractor (if different from above): Phone:
Business Address: City/State/Zip:
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** For plumbing reversal fee information, see reverse side of this form.
FEE INFORMATION
Sewer Connection: Number of Buildings X (times) $50 (per bldg) _ $ OO
vo
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-plex require I permit per address/stub.
*Multiple buildings (apartments, industrial complexes) require 1 permit per building.
(For situations not covered here, call the ' my; Utilities Division (i) 456-3604)
APPLICANT SIGNATURE: -.Q., Date: 10 - d21 y
Spokane County Division of Buildings
West 1026 Broadway Avenue * Spokane, Washington 99260 * (509) 456-3675