1999, 12-05 Permit App: 99011612 Sewer , , , , -.\
( � �!`_ 7= Spokane C. untyivision of Utilities i
'� a/ J;�,,i SEWER CONNECTION PERMIT APPLICATION FORM It ,
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 form the date of issuance. No extensions will be granted.
PROJECT INFORMATION
Job Address: //5-,P0- c 6 / .
Owner's name: ei,,,p.,e, &,,,,,,, eA
Parcel Number: Lot: Block: _ ,
Address: /1/:3 a
CHECK APPLICABLE BOXESJ/
❑ Regular Residential O New
City/State: --,v k u s't "e-- c�
❑ Dry Sewer Commercial O New Gtr p 0
Ce
❑ Repair O Temporary Zip:
❑ Addition Phone: ,-) D -r 9 y 0
U Abandonment
FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMING THE INSTALLATION MUST FIRST CONTACT THE
UTILITIES DMSION BEFORE PERMIT(S)CAN BE ISSUED.
:: SIGNATURE OF UTILITIES DMSION PERSON CONTACTED:d k 162 }15`- (J E Th1LYYI 17. a"),
CONTRACTOR INFORMATION Z r6 ��
Cone pany e): / Sate contractor license number:
`f ger , ) A -' /yl evf
Business address: 71_ "M o=--‹ Contact Name:
City/State: Sla /Late'/ Zip: ) 9-10 Cr.
Phone Number:
INTERIOR PLUMBING ALTERATIONS? (yes circle one
Fill out the information in the table below if applicat.•
Contractor(if different from above): Phone:
Business Address: City/State/Zip
**For plumbing reversal fee information,see reverse side of this form.
FEE INFORMATION
a
Number of Buildings connecting to sewer / X(times)$100(per bldg) _ $ /O 2
TOTAL FEE
• For a single-family residential unit,one permit is required;
• For a condominium,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 ND RE, COUNTY DIVISION OF UTILITIES AT 477-3604) c�
APPLICANT SIGNATURE: �� � - -7� DATE: Alec, -., 9I
Method of Payment:
O Cash 1$1 Check 0 Visa 0 MasterCard 0 Discover Card
Date: Expires:
Bankcard Number:
Authorized Signature:
Spokane County Division of Building&Planning
1026 West Broadway Avenue*Spokane WA 99260
Tel.No.(509)477-3675*Fax No.(509)477-4703*TDD No.(509)324-3166