1994, 07-07 Permit App: 94006312 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: S' 'lc j S
CITY:
ro k4 wt e
OWNER NAME: H
STATE : W'I\
CITY: Sre+w
PHONE NUMBER:
c)2_4/- Gatj
STATE: VU/
(IF KNOWN)
PARCEL NUMBER:
L/6-3 2', OS 04-/
ZIP CODE:
ADDRESS: `5-410'"�
ZIP CODE: c)c) 2
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: ADDRESS:
CITY: STATE: ZIP CODE:
PHONE NUMBER:
STATE CONTRACTORS LICENSE NUMBER:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES (NOD (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS:
CITY:
STATE:
PHONE NUMBER:
ZIP CODE:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDINtlt, 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:
DATE: 7� l 9 zy
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675