1994, 07-05 Permit App: 94006225 SewerSEWER 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: 5 F// SS //c-,pC -� PARCEL NUMBER:/f...1/3 i/ ry
CITY: 5 STATE4'L' '
' ZIP CODE: 2%z 41.4---_
/_ 5 y2 _.7_ ? ,4 -7
OWNER NAME : /C /1' /2 a •1? 44/ ADDRESS : � �' " w
CITY: Q,¢,Pw
STATE: /0iQ� ffe ZIP CODE: 7;72-2-
PHONE
??
PHONE NUMBER: 2
PROPERTY OWNER PERFORMING SEWER CONNFCTION INSTALLATION? YES
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR:
ADDRESS : G 1 1 7 E.
CITY: cippvc f\ Q. STATE: \Af,A
PHONE NUMBER: &12_14-- Cn l 82.
ZIP CODE:
STATE CONTRACTORS LICENSE NUMBER:
L-
q 9/Jore
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO) (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS:
CITY:
PHONE NUMBER:
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 $
APPLICANT
SIGNATURE:
DATE :
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675