1994, 08-15 Permit App: 94007902 Sewer4 tS
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS
SIGNED OR PERMIT WILL NOT BE ISSUUED.
JOB ADDRESS: / 06 S. tLI3
(IF KNOWN)
PARCEL NUMBER:
9t -I5 - 90 z
ENTIRETY AND
CITY: E� Ct./PC tU STATE: LOA__ ZIP CODE:
OWNER NAME: 1\k.b0,,ADR ( C7 ADDRESS:
CITYp
PHONE NUMBER: 9 J7 - a l
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION?
STATE: (.1\)%
ZIP CODE:
YES
(CIRCLE ON
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR:
CITY:
PHONE NUMBER:
STATE CONTRACTORS LICENSE NUMBER:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
13,637 LOP g. MT
ADDRESS:
STATE:
ZIP CODE:
INTERIOR ALTERATION BY:
ADDRESS: PHONE NUMBER:
CITY: STATE: ZIP CODE:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL
BE CONNECTED TO THE SEWER.
SEWER CONNECTION *It OF BUILDINGS ( X 50.00 = ,�Z� •O C.)
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00 = 37.E
TOTAL PERMIT FEE DUE $ "
APPLICANT _ 1
SIGNATURE:. �� �! 2e12,1 -Q
DATE: [ ��
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675