1994, 06-16 Permit App: 94005566 Sewerr,
, SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS
SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS:
CITY: S( )kcp.
(IF KNOWN)
ARCEL NUMBER:
ZIP CODE:
ADDRESS:
ZIP CODE:
OWNER NAME:
CITY: A
STATE:
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STATE:
PHONE NUMBER:
(.3p,
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ENTIRETY AND
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION?
YES
(CIRCLE
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: 1LG CP RI r+i(r)r1
ADDRESS: 1,3 1 (c, . 1Z4 �•
CITY: -Spale.ylue\ P.- STATE: v1A-
ZIP CODE: Ci G 21
PHONE NUMBER: 92.11 - GrrJ- �n
STATE CONTRACTORS LICENSE NUMBER: -i if G G 04(c. 2(1M ,
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO___)(CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS:
CITY:
PHONE NUMBER:
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 =.5 t) OCD
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $ 5 •0 d
APPLICANT
SIGNATURE: .
DATE:
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SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675
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