1994, 10-14 Permit App: 94010220 Sewer SEWER CONNECTION PERMIT
APPLICATION FORM °ill-. /oi ao
PLEASE NOTE: This application form must be filled out accurately and in its entirety, and signed,
or a permit will not be issued.
PROJECT INFORMATION
Job address: ;) N.__.) Owner's) name: C
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City: ev✓'9- City/State:2 -a a--, z ,
Zip: yey � Zip: 4i'12 / L / x79
Parcel number (if known): Phone:
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WILL THE PROPERTY OWNER BE PERFORMING THE SEWER CONNECTION
INSTALLATION?* Yes No
*If property owner is installing the sewer connection, they must first contact the UTILITIES DEPARTMENT for construction
requirements before the permit is issued.
CONTRACTOR INFORMATION
Contractor (company name): State contractor license number:
C4L c./,tai4S 4T / tJ 't-- -- G ,`i Y/4 ( Z) 6 5--
Business address: Utilities installers permit number:
City/State: ,, i.' 1.._> '
Zip:_ C/'2 2 1 Z- Phone: ( 2 - y;-. ,,
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INTERIOR PLUMBING ALTERATIONS (if applicable)**
Contractor (if different from above): Phone:
Business Address: City/State/Zip:
** For plumbing reversal fee information, see reverse side of this form.
FEE INFORMATION
Sewer Connection: Number of Buildings X (times) $50 (per bldg) _ $ t
TOTAL FEE
(One permit required for each separate building, shop,garage,ctc., tI,at will Le connected to the sewer)
APPLICANT SIGNATURE / C Date: / X.2
10114144.)
SPCounty
Spokane Division of Buildings
West 1026 Broadway Avenue * Spokane, Washington 99260 * (509) 456-3675