1994, 01-20 Permit App: 94000489 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.
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JOB
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JOB ADDRESS: /% )2<r
CITY: �� �Ci �5�
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OWNER NAME <<'� LncZ �
CITY:VJC
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ADDRESS:
STATE: /t-4-1
(IF KNOWN )
PARCEL NUMBER:
ZIP CODE: /-'qD� '7
PHONE:
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PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? ¥ES
IRCLE ONE)
IIF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT F CONSTRUgION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOF': (' 1 `c 6(-2 `i /(1 c,'�"C` e'�� DDRESS :
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CITY: STATE: PHONE:r
4-7- 2 2"
STATE CONTRACTORS LICENSE NUMBER..:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
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.
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
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