1994, 10-04 Permit App: 94009726 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.
(IF KNOWN)
JOB ADDRESS:56/�� ' "e<y PARCEL NUMBER: 43. 2
CITY: , lif,�iYcL STATE : !:;‹ ZIP CODE: �%-1C�
ADDRESS: ,�7.-G� �/Z'!y (
OWNER NAME: ii.
CITY:
PHONE NUMBER: .IS �— l 751
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION?
STATE: �—l-i'Y ZIP CODE:
*TT
NO
IRCLE ONE)
PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR:
CITY:
PHONE NUMBER:
STATE CONTRACTORS LICENSE NUMBER:
UTILITIES INSTALLERS PERMIT NUMBER:
ADDRESS:
STATE:
ZIP CODE:
INTERIOR PLUMBING ALTERATIONS? YES (N l) (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 =
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $
s
APPLICANT
SIGNATURE:
SPOKANCOUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675