1994, 01-20 Permit App: 94000487 Sewer614 -1-1-g q
c +5 '5LJ
SEWER CONNECTION PERMIT APPLICATION FORM
HIS APPLICATION FORM MUST BE FILLED
DOT ACCURATELY AND IN ITS ENTIRETY
kND SIGNED OR PERMIT WILL NOT BE ISSUED.
TOB ADDRESS : --
�ITY:
1)0
(IF KNOWN )
t , PARCEL NUMBER:
STATE: ZIP CODE:
OWNER NAME
CITY:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION?
t
4, ADDRESS:
STATE= ��1 PHONE:
YES ... NO
(CIRCLE ONE)
cIF PROPERTY OWNER INSTALLING SEWER, THEY
MUST FIRSTE COONTACTSTHE. UTILITIES
DEPARTMENT CONSTRUC ON REQUIREMENTS
CONTRACTOCL6t,( 1( t7/ADDRESS:
CITY:
STATE CONTRACTORS LICENSE NUMBER..:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
STATE:
PHONE:
INTERIOR ALTERATION WORK BY..:
ADDRESS: PHONE=
CITY:
STATE:
ZIP CODE:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC
THAT WILL BE CONNECTED TO THE SEWER.
to
SEWER CONNECTION
# OF BUILDINGS X 50.00 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS
X 35.00 =
TOTAL PERMIT FEE DUE $
/
APPLICANT
SIGNATURE
,
16-
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 (509)456-3675