1999, 10-04 Permit App: 99009324 Sewer Spokane County Division of Utilities
SEWER CONNECTION PERMIT APPLICATION FORM q "
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
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that sewer permits arc valid for 12 months form the date of issuance. No extensions will be granted.
PROJECT INFORMATION
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Job address: Dry Lute Sewer? Own is trans%;
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City: 6( n
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tip: /tel 2-o i, Zip: 9 20 (p
?arcel Number(if(mown): Phone:
irst-time contractors or home-owners performing the installation must first contact the Utilities Division in person or via phone[456-3604j before a
ernrit can be issued.
Name of Utilities Division person contacted: Q:f VEg---5
CONTRACTOR INFORMATION
'ontractor(company name): Sate contractor license number:
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;usiness address: (7317 5, CR E /31 A nJ b Contact Name:
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any/State: /Yl Eb f GR L- 1-.4 FC Ef WA Zip: '"?a - Phone Number: (50q) Y FS a -
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INTERIOR PLUMBING ALTERATIONS?(yes .116 circle one • •
Fill out the infomsation in the table below if applicable**
Contractor(if different from above): - Phone:
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Business Address: City/State/Zip- •
aIsgI>G t_�( I cy uC�?l2€ E.J Ac12E"S / tcJ�. 4`016
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Sewer Connection: Number of Buildings 1 X(times)$100(per bldg) — S /00-00
TOTAL FEE
For a single-family residential unit,one permit is required;
For a condosrtinitun,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)
'PLICANT SIGNATURE: _ ii.r3.4,A-P-4=i G - DATE: Jo- —Qy
.!tltod of Payment:
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Cash 0 Check 0 Visa 0 MasterCard 0 Discover Card •
Date: Expires:
Bankcard Number.
Authorized Signature:
County Division of Building& Planning
West Broadway Avenue 4 Spokane \VA 99260