1994, 09-30 Permit App: 94009660 SewerSEWER CONNECTION PERMIT APPLICATION FORM
*TRIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
560'107%
JOB ADDRESS:S-T /116/e/2ow C�
(IF KNOWN)
PARCEL NUMBER:
CITY: S olv STATE: W XL ZIP CODE:
OWNER NAME: AAL 2 S`)&-rMl s ADDRESS:
CITY: STATE:
PHONE NUMBER:
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 IS ISSUED.
CONTRACTOR: /� a- Ah
- 0,04 ADDRESS: S' 9d/5 4)/t47,5'
ZIP CODE:
CITY: U46LG`rF-o-rcD STATE: itL4 ZIP CODE: 99.036
PHONE NUMBER: 9Z* -- 4/7 8- Z
STATE CONTRACTORS LICENSE NUMBER: 4---424)67
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS?
INTERIOR ALTERATION BY:
ADDRESS: PHONE NUMBER:
CITY: STATE: ZIP CODE:
-* 242Eo
*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:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675