1993, 09-27 Permit App: 93008922 SewerSEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS: 5 /4 /7 &L kPARCRCE KNOWN) }
/ C 2
EL NUMBER: 9;71/i6
CITY:`5�QB/�4W-P STATE: ZIP CODE: < /v/
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OWNER NAME : b5 W W 0. %J ADDRESS: 3 /4°
CITY: 5 6,4 /Ke STATE: V14- PHONE: Z 92-16
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION?
NO
(� LE ONE)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED..
CONTRACTOR: ADDRESS:
CITY: STATE: PHONE:
STATE CONTRACTORS LICENSE NUMBER..:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY..:
ADDRESS: PHONE:
CITY: STATE: ZIP CODE:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC
THAT WILL BE CONNECTED TO THE SEWER.
SEWER CONNECTION # OF BUILDINGS / X 50.00 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $ 50
APPLICANT
SIGNATU
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675