1994, 06-14 Permit App: 94005554 SewerSEWER CONNECTION PERMIT APPLICATION FORM
4S-07
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS:
CITY :
OWNER NAME:
CITY: STATE: ZIP CODE:
STATE:
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dC�ri'�2h
(IF KNOWN)
PARCEL NUMBER:
ZIP CODE: 91'9'02/i
ADDRESS:
PHONE NUMBER: 9,24-5-71-7
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
EIRCLE
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: 5 o(4 ( vA C 4, c ADDRESS: 11E;11 V(1 1 i,e.y ala
CITY: L5 O I_tf).17_, STATE: W,4 ZIP CODE: QQZ(7G�
PHONE NUMBER: q 2L, - q
STATE CONTRACTORS LICENSE NUMBER: N'.S ([�l\I 4 12_ -1 i
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS: PHONE NUMBER:
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 $
APPLICANT
SIGNATURE:
DATE: CO//,///;2/
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675