1994, 03-03 Permit App: 94001666 Sewer9L/�1���
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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.
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JOB ADDRESS:
S �%/J��, ( /1� PARCEL NUMBER:
CITY: /
�� �iJ.tQ � STATE : C,li C� � ZIP CODE: ���i
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OWNER NAME: -ii)i 7 ta-4.4. d4A--) ADDRESS:
CITY: STATE: PHONE: poPg_ -57-7e
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE ONE)
*IF PROPERTY OWNER 'INSTALLING SEWER, THEY MUST FIRST CONTACT THE .UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT XS XSSUED.
CONTRACTOR: N' 4 S CO (15+(kAr on ADDRESS: 11,811 E . Va..11eL (g__
CITY:14,011�e. STATE:
CIC12-040,
STATE CONTRACTORS LICENSE NUMBER..: N•S C n [V 44 4e 12.3 -c
UTILITIES INSTALLERS PERMIT NUMBER:
v lA PHONE: SDG . q 2-6 • GI 6, 14-
INTERIOR PLUMBING ALTERATIONS? YES F (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.
1 �
SEWER CONNECTION 0 OF BUILDINGS / X 50.00 =
INTERIOR PLUMBING ALTERATIONS: 11 OF BUILDINGS X 35.00 =
ee
TOTAL PERMIT FEE DUE $ _5-2%
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675
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