1994, 08-11 Permit App: 94007718 Sewer61)Lte,Awdei ct4--771g
SEWER CONNECTION PERMIT APPLICATION FORM `�("i1'S- gj
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS: 5 c'Z p(IF KNOWN)
- : c v N e PARCEL NUMBER:
CITY: STATE: '--)`i
OWNER NAME: �� k4-('\
ZIP CODE: �9zo6
ADDRESS: ifY0 S_
CITY• c'U�c(aif' STATE: ZIP CODE: 9?-Ziw
PHONE NUMBER: '?-2-"5---"?
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
NO
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: ''"' j e V s ADDRESS:
CITY: SFak�
PHONE NUMBER:
STATE CONTRACTORS LICENSE NUMBER:
UTILITIES INSTALLERS PERMIT NUMBER:,
INTERIOR PLUMBING ALTERATIONS?
INTERIOR ALTERATION BY:
ADDRESS:
CITY:
STATE :
ZIP CODE: `(92106
(CIRCLE ONE)
STATE:
PHONE NUMBER:
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: gbo/9/
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675