1996, 08-29 Permit App: 96007131 SewerSEWER CONNECTION PERMIT APPLICATION -TO
*THIS APPLICATION FORM MUST BE FILLED OUT
SIGNED OR PERMIT WILL NOT BE ISSUED.
)(2Ait C
JOB ADDRESS:
11
Ll
CITY: SANE Wi614. STATE:
OWNER NAME: t1ANZZCE.G. DOUGLASS
CITY: SPOKANE
PHONE NUMBER: (509) 483-6532
STATE:
WA
ACCURATELY
WA
A/14cLk.4 2(,+ -/Id TY AD
N ITS ENTR�I
LSE.. =z
(IF KNOWN)
PARCEL NUMBER:
ZIP CODE:_41L12._____
ADDRESS: 815 E. ROSEWOOD AVE.
ZIP CODE: 99208-5599
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
EIRCLE ONE)
*IF PROPERTY OWNER INSTALLING
REQUIREMENTSMUST
BEFOREFIRST
PERMITCONTACT
ISSUEDUTILITIES
DEPARTMENT FOR CONSTRUCTION
CONTRACTOR: CANNON EXCAVATING ADDRESS: P.O. BOX 28778
CITY: SPOKANE STATE: WA
PHONE NUMBER: (509) 467-6522
STATE CONTRACTORS LICENSE NUMBER:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES
INTERIOR ALTERATION BY:
ADDRESS:
CITY: STATE:
ZIP CODE: 99208-8778
aci (\f &EL ol iD 21-
( NO
(CIRCLE ONE)
PHONE NUMBER:
ZIP CODE:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL
BE CONNECTED TO THE SEWER.
SEWER CONNECTION
• $ OF BUILDINGS 1 X 50.00 = 50.00
INTERIOR PLUMBING ALTERATIONS:t OF BUILDINGS
TAL SRMIT FEE DUE 35.00 $
APPLICANT
SIGNATURE:
DATE:
SPOKANE COUNTY DEPARTMENT
JAOF BUILDING0
WEST
9) 456-3675
WEST 1026 BROADWAY AVENUE, SPOKANE,