1994, 03-08 Permit App: 94001797 SewerSEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE
FILLED
LIEDUOUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOTBE
( IF KNOWN)
SC�'/� i,/ / 1C t PARCEL NUMBER:
JOB ADDRESS:
CITY= %)'21.2 C-)S1�UA4,--i- STATE : _ to'�___ ZIP CODE:
n EX C E- .,"
OWNER NAME : 9264" ✓v (/I O)UNM-,ADDRESS: C a C (�
CITY : _;-ASTATE: � PHONE: 5 9 7 71
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? (CES NO
RCLE ONE)
*IF PROPERTY OWNER INSTALGSEWER, THEY MUST REQUIREMENTS BEFOREIRST PERMIOTNISCT THE ISSUE0. UTILITIES
DEPARTMENT FOR CONSTRUCTION
..' co ADDRESS: i‘ `%Z3 /5)4.1J,_,,,
CONTRACTOR: Ci4) j<rllL< Sr.,
PHONE: (049 ,W.--02-73
clq---/ 797
n
CITY: 1,/. 941,4 STATE: b1641 -
STATE CONTRACTORS LICENSE NUMBER..:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES
INTERIOR ALTERATION WORK BY..:
ADDRESS: PHONE:
CITY: STATE: ZIP CODE:
(CIRCLE ONE)
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC
THAT WILL BE CONNECTED TO THE SEWER.
SEWER CONNECTION # OF BUILDINGS 1 X 50.00 = 5r)-oo
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $ SD
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675
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