1994, 07-18 Permit App: 94006680 SewerQ4s _ ge q
SEWER 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: -90f S (IF KNOWN)
A ��% /��Y, PARCEL NUMBER:
CITY: �,�L'�/L�,E STATE: C'c ZIP CODE:
OWNER NAME: -A ADDRESS:
STATE: ��,/ ZIP CODE:
PHONE NUMBER: Xf'
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE O
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: TI C, CIS (15+ris r -E r� n ADDRESS: �j I 1p e: .
CITY: _ C� �, v. STATE: yn A- ZIP CODE: q q Zl (m
PHONE NUMBER:
STATE CONTRACTORS LICENSE NUMBER:G G D '1 M
UTILITIES INSTALLERS PERMIT, NUMBER:
INTERIOR PLUMBING ALTERATIONS?
INTERIOR ALTERATION BY:
ADDRESS:
CITY:
YES O (CIRCLE ONE)
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: C�" DATE : L�
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675