1993, 11-03 Permit App: 93010621 Sewer�SzZ�.ter®z
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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: /972-
(IF KNOWN)
PARCEL NUMBER:
CITY: j>-' STATE ) .— ZIP CODE:
OWNER NAME: 44 tjADDRESS:
CITY: STATE: PHONE: 9_2,--
PROPERTY
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PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES (NS')
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR W LLi,1 -�'� ADDRESS: /?CCITYTY: STATE: tee? y PHONE: 0-C
STATE CONTRACTORS LICENSE NUMBER..: ,/?/ TG-) /9.21✓ /
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES (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 $ Gam!
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675