1994, 10-20 Permit App: 94010470 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.
JOB ADDRESS:
� 5 ci 17- rict�
(IF KNOWN)
PARCEL NUMBER:
CITY: SIrr)(A CUAQ STATE: LA- ZIP CODE:
OWNER NAME:V1ZCe Li i.)00SSSc ADDRESS: ,515 KO5J2k.VD<ll
A
CITY: S���a.� STATE: LA ZIP CODE: /gZOS
PHONE NUMBER: eOel-c1,ir3-14,5 3 7 ---
PROPERTY
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES lU
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: (�VLPl.nel JWQGI,V4 ADDRESS:
CITY: Q STATE: L.J/ ZIP CODE:
PHONE NUMBER: °I 9 9-t.) 13
STATE CONTRACTORS LICENSE NUMBER:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES �O (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS: PHONE NUMBER:
CITY: 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 $
DATE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675