1994, 05-27 Permit App: 94004820 Sewer6P
k PSI
CHIS APPLICATION
SIGNED OR PERMIT
SEWER CONNECTION PERMIT APPLICATION FORM
FORM MUST BE FILLED OUT ACCURATELY AND IN ITS
WILL NOT BE ISSUED.
)B ADDRESS : 6 l3 d C' l lit,
ETY: ZS
STATE:
4NER NAME : rZAN-CW ra_
CTY :
SONE NUMBER : 01 /1)64,
(fL tSZ-0
qt -is
ENTIRETY
z.) - y
AND
(IF KNOWN)
PARCEL NUMBER:
ZIP CODE: 671?.1(f-;
ADDRESS:
STATE: ZIP CODE:
OPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION?
NO
LE ONE)
IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
DNTRACTOR: 4 , 5 E 4U ATI 4C
ITY:
ADDRESS:
STATE: ZIP CODE:
HONE NUMBER:
TATE CONTRACTORS LICENSE NUMBER:
TILITIES INSTALLERS PERMIT NUMBER:
NTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
NTERIOR ALTERATION BY:
DDRESS: PHONE NUMBER:
ITY: 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 $
5b. 00
So. o S
,PPLICANT
IGNATURE: DATE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675