1994, 10-20 Permit app: 94010472 Sewere... -
SEWER CONNECTION PERMIT APPLICATION FORM ep7
7
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
1, (IF KNOWN)
JOB ADDRESS: 15TLi _ riGQ.c,n D{ PARCEL NUMBER:
CITY: `c-SipUIcl.l,t STATE: GA ZIP CODE:
OWNER NAME: L cavi,, t 7 1J 6 i5 �j IG�55 c ADDRESS: �I� c_ R C�.:P.A-J(7vc,�
U
CITY: G STATE: W ZIP CODE: ,ITL
PHONE NUMBER: 1I,$3 .05,32 -
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES 0
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
1X3&' O'i ,Zc caO i t ADDRESS:
CONTRACTOR:
CITY: 64 - STATE: (.Jr ZIP CODE:
PHONE NUMBER: 11L1-301�J
STATE CONTRACTORS LICENSE NUMBER:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YESC!!)(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 $
APPLICANT
SIGNATURE:
IGNATURREE %G� J��^
SI -f'
DATE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675