1994, 08-31 Permit App: 94008460 Sewera
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WI L NOT BE ISSUED.
3 O (IF KNOWN)
JOB ADDRESS: (ve..rc-`Citi PARCEL NUMBER:
CITY: S c �� STATE:--�ZIP CODE:
OWNER NAME: A4 ;k� ah, 0 CA ADDRESS:
CITY:
STATE: ZIP CODE:
PHONE NUMBER: 7,72 - 000
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: 1 i� i / i ( , DDRESS : PO IDY 7 S --
CITY:
CITY: 0 _/> - STATE: C ZIP CODE: / 9 7 0 5
PHONE NUMBER: '
STATE CONTRACTORS LICENSE NUMBER: 0 V,J %1'1' 07
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS:
CITY: STATE: ZIP CODE:
PHONE NUMBER:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL
BE CONNECTED TO THE SEWER.
SEWER CONNECTION •# OF BUILDINGS / X 50.00 = S
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