2007, 05-22 Permit App: 07003252 Sewer Spokane County Division of Utilities
SI:\X/I::lt CONNECTION PERMIT APPLICATION FORM
'1.I?.\SI?NOTE: Thin appLrau"„ 'mutt br lillrrl out accurately and in its entirety,and signed,ors Remit will not be issued. Sewn permits are valid for 12
tombs form the date of t„uanir• A separate riglu•uf•w•ay permit is required for any work.perfoentsd'a or from the public right-of-Way. an interior
Iornbing and electrical work 'Num., :rlrrrau•prrmu •
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S2B2R23- PROJECT INFORMATION (-57" 3R5.
nb Address: A tkI• \_ A:
.��.s\5-•F`"Ci- ` name:Owner's nam
'arca Number. ' I.rti: Block: t•-••••
'mica Name•. Address \, \� c c c �J
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Jl.11)Name: t
I Ciry/State: •
CHECK APPLICA LE I3OXIS •
'Regular (Residential (iNew Zap:
] Dry Sewer 0 Commercial 0 New •mac r�
] Repair 0 Tempttrrry Phone:
Addition
O Abandonment
+ FIRST TIME CONTRACTORS OR HOME OWNERS PERFORMING THE INSTALLATION MUST FIRST CONTACT THE
UTILITIES DIVISION BEFORE PERM IT(S)CAN BE ISSUED.
SIGNATURE OF trri (TIES DIVISION PERSON CONTACTED:
•
Contractor(company name): . _ Sate contractor license numbers
• •
Business address: Contact Name•.
•
City/State: Zip:
Phone Number. '
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INTERIOR PLUMBING ALTERATIONS?(yellirj)irde one
Fill.ai for irfwnrNirr ie!be tibk britt fepfriesMift •
0 County City of Spokane Milky
Contractor(if different from above): ' Phone.
Business Address: City/State/Zip
"For Spokane ContOl morsels ea►finssatiers, lora dtpilXy •
FEE INFORMATION
Number of Buildsnp connecting to sewer X(times)S100(per bldg)=S + S10.00= SPOS:awseaaar
alt2lrr Op WAY PUNT
• For is sisp(srtrir raitMwist Yr W.ow prrruw is rewired;
• Far s wsiimaiirro.rosakw•e,tktplea.triplex or lowpk x wlh wpsss,osnteis ip(ss desewswal til tot rims)emoso adieu ss/upsets NA.owe pawls it totptisd pe disc psr twig
• P. silk ducats,rwples N Cougges wuh sinule awrlee{kip.Me won is/vpied w��► �
• Wei* w
(spasrwtx.icomplexes)dustriacomplexes)wird single uim pW .ttwe vide rewindp-.bolding{,ni'Med motr ea ars.
(FOR SITUATIONS NOT COVERED HERE,CALL THE COUNTY DIVISION OP=tin=AT 477-3404)
Is any of the work to be performed in or from the pub 'c right-of-way? kg..Yes 0 No
0 County at City of Spokane Valle
APPLICANT SIGNATURE: �, _ DATE: `1-1..1-
Owner or Contractor(circle one)
Method of Payment
O Cash 0 Check 0 Visa O MasterCard O Discover Card , •
Date: Expires:
Bankcard Number:
Authorized Signature: r
Spokane County Department of%aft and insuring
11126 wvits Itroodwsv Avenue•*thane WA 9911x0
•, •••.. rS,r)1.177.u,7S• t,.N't.(54r))477.71914•il)1)Nn./%n9)477.71 SS