1994, 01-18 Permit App: 94000424 Plumbing Reversal 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: 3 / 7/ 3 PARCEL NUMBER:
CITY: S ()/69/V STATE: t�)� ZIP CODE: / ! 2/-C
OWNER NAME: /2/9 G)/L7 T /?GSS" ADDRESS: S /7 i ? 2 /EK ,'D
CITY: c' Gr/<,/mi- STATE: PHONE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? (CIRCNO
LE ONO)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: ADDRESS:
CITY: STATE: PHONE:
STATE CONTRACTORS LICENSE NUMBER. . : -----
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? eES) NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY . . : Z/
4› •
•
ADDRESS: PHONE:
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
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675