1995, 10-04 Permit App: 95008106 Sewer SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
(IF KNOWN)
JOB ADDRESS : 11 -ACI 2 C,I 'g (` PARCEL NUMBER:
CITY: SPOKANE STATE: WA ZIP CODE: q9
OWNER NAME: LA.NZCE .G. DOUGLASS ADDRESS : 815 E. ROSEWOOD AVE.
CITY: SPOKANE STATE: WA ZIP CODE: 99208-5599
PHONE NUMBER: (509) 483-6532
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: CANNON EXCAVATING ADDRESS : P.O. BOX 28778
CITY : SPOKANE STATE: WA ZIP CODE: 99208-8778
PHONE NUMBER: (509) 467-6522
STATE CONTRACTORS LICENSE NUMBER: ...11 /L) 11„) () k qtr- ,a._<1".
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (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 1 X 50 . 00 = 50.00
INTERIOR PLUMBING ALTERATIONS : # OF BUILDINGS X 35 . 00 =
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE: DATE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675