1994, 01-20 Permit App: 94000486 SewerSz1
Rests 53
SEWER CONNECTION PERMIT APPLICATION FORM
PHIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
NND SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS: 2C <'s
CITY: / C <'c<c <£
STATE : f1
OWNER NAMEC 7 / ( [ chi C /(
J
CITY: C,��`a�
STATE: l ��
PROPERTY OWNER PERFORMING SEWER
0
(IF KNOWN)
PARCEL NUMBER:
ZIP CODE: (f/-e-
�/ Jc
PHONE : /2 j - i' J
CONNECTION INSTALLATION? E NO
'CIRCLE ONE)
:IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED..
CONTRACTOR (rk /c
? e' Y C t 'ADDRESS :
PHONE : 7
CITY: STATE:
STATE CONTRACTORS LICENSE NUMBER..:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES
INTERIOR ALTERATION WORK BY..:
ADDRESS: PHONE:
CITY: STATE: ZIP CODE:
NO (CIRCLE ONE)
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC
THAT WILL BE CONNECTED TO THE SEWER.
SEWER CONNECTION
INTERIOR PLUMBING ALTERATIONS:
# OF BUILDINGS X 50.00 =
# OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $
0
APPLICANT
SIGNATURE
7
•
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675