1995, 11-21 Permit App: 95009730 Sewer SEWER CONNECTION PERMIT q5- q9it>6
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 Owner's m .
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City: City/State:
Zip: • Zip:
Parcel number(if known): Phone: c, 2._ --- to (2----"First-time contractors or home-owners performing the installation must first contact the utilities department(in person
or via phone[456-3604])before a permit can be issued.
Name of Utilities Division person contacted:
CONTRACTOR INFORMATION
Contractor(company name): State contractor license number:
A(ira ory Con 'tA .a.g 2. Ni 1
Business address: `1 Utilities installers permit number:
Po Pr))1 142,62.
City/State: `n .t; VJA
Zip: Gj cj 2t Phone: q z,Es • 05c cf
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INTERIOR PLUMBING ALTERATION' . o) circle one /e'-Vv tit
Fill out the information in the table below if appli - s e**
Contractor(if different from above): Phone: c12`1 - O 91,'R
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Business Address: City/State/Zip:
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FEE INFORMATION
Sewer Connection: Number of Buildings 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 plexes require 1 permit per address/stub.
*Multiple buildings(apartments, industrial complexes)require 1 permit per building.
(For situations not covered ere,call the Co ty Utilities Division @4S6-3604)
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APPLICANT SIGNATURE: :' -
Date:
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Spokane County Division of Buildings
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.
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