1994, 10-28 Permit App: 94010821 Sewer tppe., SEWER CONNECTION PERMIT
�% APPLICATION FORM
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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:
510 1 6'16 UE Sewer? (Y/N)
rn Ji M y ikr• IAD
City: 5 Pomo City/State: OKarc
Zip: Zip:
Parcel number (if known): Phone:
53 s— 6
First-tinge contractors or home-owners performing the installation must first contact the utilities department (in
person or via phone [456-3604]) before a permit can he issued. -Z 0 K T SS 4,44;Name of Utilities Department person contacted: L- e (5).
CONTRACTOR INFORMATION
Contractor (company name): State contractor license number:
� l20 , Saks L l C T 550 OBB
Business address: Utilities installers permit number:
36135 2cn' .1vE- 5
City/State: y 30 CDC) lU
Zip: 9g'a3 Phone: Z3712
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 I X (times) $50 (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-pler require I permit per address/stub.
*Multiple buildings (apartments, industrial complexes) require 1 permit per building.
(For situations not covered here, call the County Utilities Division @ 456-3604)
APPLICANT SIGNATURE: Date: 10
Spokane County Division of Buildings
West 1026 Broadway Avenue * Spokane, Washington 99260 * (509) 456-3675