1994, 10-20 Permit App: 94010473 SewerSEWER CONNECTION PERMIT APPLICATION FORM
qt./ -'J73
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS:
CITY: ,9 _ 1 STATE: ZIP CODE:
OWNER NAME: i L �. . •_ L ADDRESS: SIS Z , 'P1,O SO t-oUnd
C �
CITY: C.�%IS LLr.Q C-)� ZIP CODE: 79z65(
PHONE NUMBER: ' (cS 3 Z
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE ONE)
1o01I I Ka-ck:
(IF KNOWN)
PARCEL NUMBER:
STATE:
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT F R CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: nktnin_ ad644/ ADDRESS:
CITY: 8i0 STATE: • ZIP CODE:
PHONE NUMBER: G, !--30`3
STATE CONTRACTORS LICENSE NUMBER:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES 10 (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
X
SIGNATURE :�
DATE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675