1994, 06-03 Permit App: 94005080 Sewer9 -sog-a
SEWER CONNECTION PERMIT APPLICATION FORM
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*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
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JOB ADDRESS:
(IF KNOWN)
PARCEL NUMBER:
CITY: I/ e r 4 cia, 4 STATE: Wet ZIP CODE: q q 0 3 7
OWNER NAME : /,/a v , d 144 /J P -P e 4I el' ADDRESS: C / 7 0 3 / u /' iz f
CITY: 1/29 (6 dee /-r STATE: W q_ ZIP CODE: 9 0 3 7
PHONE NUMBER: 9 L-2_ / Gl
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION?
NO
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR:
CITY: STATE: ZIP CODE:
PHONE NUMBER:
STATE CONTRACTORS LICENSE NUMBER:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS: PHONE NUMBER:
CITY: STATE: ZIP CODE:
ADDRESS:
*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 $
APPLICANT
SIGNATURE
IGNATUR-
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DATE: 6' 3
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SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675