1994, 06-28 Permit App: 94006030 Sewerc
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.
JOB ADDRESS :
CITY : E c)
OWNER NAME :
CITY:
(IF KNOWN)
PARCEL NUMBER:
STATE : &).,Q ZIP CODE: 9'901)6
4/V S
PHONE NUMBER: 9? N - 0 1493
ADDRESS : A--t-
STATE: ZIP CODE:
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 :.j12;n \ 4I:Iz 1.. -L XGca,J Ct 't. n q ADDRESS: 1 1 1 2- /\/. M QYfl r r
CITY : r.#A,
PHONE NUMBER: C?z a -
STATE :
ZIP CODE: qq2/(,,
STATE CONTRACTORS LICENSE NUMBER: 7b M $ T L- - / L -4 I. k M
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES CID (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 X 50.00 = Cf. -0 51-54
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $ Cc)
APPLICANT
SIGNATU
DATE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675