1996, 09-06 Permit App: 96007466 Sewer SEWER CONNECTION PERMIT ` '
0 .
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 from the date of issuance. No
extensions will be granted.
PROJECT INFORMATION
Job address: Dry Line e, Owner's name: AO �15
1-41
E. la /j /- _ Sewer? (1 --p/iii_ i-,-,n1,14-Al r K
1( �,
City: � �/r� City/State ►. � �a/� �-
Zip: IL
%{V Zip: OA' T/I'
Parcel number(ifknown): Phone:
45204-3133 ( '/o) 63q2—!(15 q2.I. -P7
First-time contractors or home-owners performing the installation must first coct the utilities department(in person
or via phone[456-3604]) before a permit can be issued
Name of Utilities Division person contacted: . inI lv
CONTRACTOR INFORMATION
Contractor(company name): State contractor license number:
tx` A -4--eikin e,rAi37h►C7-/CYVS:r4 SC //0 o A
Bu ipess address: Utili ies installers permit number:
1l l aD F i-of fE3t /v ,l
City/St t�:T LviL/L , (.0,(4Zip: Y((,�� Phone: — 7/
INTERIOR PLUMBING ALTERATIONS? (yeno) circle one
Fill out the information in the table below if applicable*
Contractor (if different from above): Phone:
Business Address: City/State/Zip:
Pidigiti'I��a + **For plumbing;reversal fee information,see reverse side of thus form
FEE INFORMATION
Sewer Connection: Number of Buildings 1 X(times) $50(per bldg) = $ `1D.(Y')
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 1 permit per address/stub.
*Multiple buildings(apartments, industrial complexes)require 1 permit per building.
(For situatio s not covered here ,l the County Utilities Division @ 456-3604)//�� �}
APPLICANT SIGNATURE: /li , i i Q4(71I, Date: I U /�I /
Spokane County Division'" ildings
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.
V25195 c\winr.,$k