1994, 09-30 Permit App: 94009659 SewerSEWER CONNECTION PERMIT APPLICATION FORM
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*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL -/ NOT BE ISSUED.
(IF KNOWN)4
JOB ADDRESS: A) ' -4f/ ///
2/ O.3"w 6- PARCEL NUMBER:
CITY: S Pa STATE: 'w A ZIP CODE:
OWNER NAME: Au 4 5e'er sr j ADDRESS:
CITY: STATE: ZIP CODE:
PHONE NUMBER:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES N_O
(CIRCLE 0
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTpR: �C odera'r /�. l o4J6 ADDRESS: s 9z/is �'4/DD5 /
CITY: LJ,OttYlnr/P%J STATE: WA ZIP CODE: 99°36,
PHONE NUMBER: Q2/:. I7S'2._
STATE CONTRACTORS LICENSE NUMBER: to/)4 4- /e42.4C fa
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES 0 (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 :If 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