1994, 10-10 Permit App: 94010010 Sewer r'
SEWER CONNECTION PERMIT
APPLICATION FORM
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: 4 r Owner's name:
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City: Q /Ct(L/L s City/State: �s,1_yu1_
Zip: 9'9d l4 Zip:
Parcel number (if known): Phone:
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:
t1 k6 IC/7/ 5�,1 77<c
Business address: Utilities installers permit number:
City/State:
Zip: Phone:
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) _ $ 50,0 d
TOTAL FEE
(One permit required for each separate building, shop,garage, etc., that will be connected to the sewer)
APPLICANT SIGNATURE: Date:
wiles
Spokane County Division of Buildings
West 1026 Broadway Avenue * Spokane, Washington 99260 * (509) 456-3675