1994, 07-18 Permit App: 94006671 SewerSEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN
SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS : / 0A s,
CITY : 0pWri{- A/ i=s
STATE:
STATE :
OWNER NAME: /4V,019. S AZ:.1, &,/v/
CITY: /9O76X/,?4^:3-5-8,/
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PHONE NUMBER: A to " .3 ,/
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION?
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ITS ENTIRETY AND
(IF KNOWN)
PARCEL NUMBER:
ZIP CODE:
ADDRESS:
ZIP CODE:
YES
(CIRCLE
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
ADDRESS: I3isIL, � • 1234' A -/c,•
CONTRACTOR: C_ • l
CITY: • S nr;YcM v, -
PHONE NUMBER: 9 `2fl -
STATE: 14%A ZIP CODE: 61c1'��� (.
STATE CONTRACTORS LICENSE NUMBER: i G C. 0 -A- 2 '7 M (o
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS:
CITY: STATE: ZIP CODE:
PHONE NUMBER:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL
BE CONNECTED TO THE SEWER.
SEWER CONNECTION • # OF BUILDINGS / X 50.00 =,51),(70
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $ _S -77,0C)
SPGLITURE
SIGNATURE:
DATE: % ?/
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675