1994, 09-15 Permit App: 94009038 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: 51 261t � ( IF KNOWN)
�' T115 PARCEL NUMBER:
CITY: �9 ��.t� X STATE •
� r _
OWNER NAME: Z'
CITY• STATE:
ZIP CODE:
ADDRESS: -
ZIP CODE:
PHONE NUMBER: I P- 2 S 4 c
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES (Q''
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: ADDRESS:
CITY: STATE: STATE• ZIP CODE:
PHONE NUMBER: Z 2 �? �
STATE CONTRACTORS LICENSE NUMBER: W(� O 5� ? /OC --
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? 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