1995, 03-14 Permit App: 95001296 Sewer 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.
PROJECT INFORMATION
Job address: Owner's name:
City: City/State:
Zip: Zip:
Parcel number (if known): Phone:
WILL THE PROPERTY OWNER BE PERFORMING THE SEWER CONNECTION
INSTALLATION?* Yes No
*If property owner is installing the sewer connection, they must first contact the UTILITIES DEPARTMENT for construction
requirements before the permit is issued.
CONTRACTOR INFORMATION
Contractor (company name): State contractor license number:
Business address: Utilities installers permit number:
City/State:
Zip: Phone:
INTERIOR PLUMBING ALTERATIONS (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
Sewer Connection: Number of Buildings / X (times) $50 (ter bldg) _ $
TOTAL FEE
(One permit required for each separate building, sho i gars;e e that will be connected to the sewer)
APPLICANT SIGNATURE: /%/ Date:
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Spokane County Division of Buildings
West 1026 Broadway Avenue * Spokane, Washington 99260 * (509) 456-3675