1994, 09-15 Permit App: 94009040 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: I ?O r
CITY:
OWNER NAME:
(IF KNOWN)
PARCEL NUMBER:
STATE: a ZIP CODE:
CITY:
PHONE NUMBER:
STATE: G� l
ADDRESS:
ZIP CODE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES (1O J
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: n74) %/- - ADDRESS : J `) l (// �'G e
CITY: C��.e,1,(:c..6,1—e`; STATE: 4 X-_ ZIP CODE: 1
PHONE NUMBER: 7L 7 % 76
STATE CONTRACTORS LICENSE NUMBER: Y V L U t�S� ( c o Cj c P C_
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS:
CITY:
STATE:
PHONE NUMBER:
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 $
APPLICANT
SIGNATURE:
DATE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675