1994, 01-18 Permit App: 94000413 Sewer L520 [ , I I L:! ciL 14-13
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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 .
( IF KNOWN )
JOB ADDRESS: , '22 �� 2Age k/% kl/ PARCEL NUMBER: 59 O/ /1 2. 7
CITY: 770A-7,4/2 STATE: frid-tr,J1, 7 ZIP CODE: 72O
OWNER NAME:/ // / k11 ADDRESS: S� n2'¢
CITY: 5/7c—M4 STATE: IM - PHONE: 2‘-Zss1-ru
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? (Yp NO
RCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: ADDRESS:
CITY: STATE: PHONE:
STATE CONTRACTORS LICENSE NUMBER. . : "'—'—'-
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (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.
SEWER CONNECTION - #
1 OF BUILDINGS X 50.00 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE � //" �dr2 :
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675