1994, 04-05 Permit App: 94002793 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.
(IF KNOWN)
JOB ADDRESS : t 3 O 3. f 11 4 1 0 (.1Jit PARCEL NUMBER:
CITY: l�1)0v'—e STATE: LL) A ZIP •CODE: �q 1
OWNER NAME : —T 0 LV vvk o L
ADDRESS : .. �� i s ►'i -�I
CITY: 131,()C1tj ,c' LTJ �\ STATE: C..) t ZIP CODE: (1C1,73 I )-
PHONE NUMBER: q
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE 0
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: Z - O/15' ' u c or ADDRESS: 7 � ((� £ , ,E3(b ri Jl.L /
STATE: N'JA ZIP CODE: gQ:112
CITY: �,pnY,r�.II
PHONE NUMBER: R Q I - q,G1 !-1 c
STATE CONTRACTORS LICENSE NUMBER: Z. li L Sr G - j q 4 H
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES IT) (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS:
CITY:
STATE:
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 / X 50.00 = C) 'U/
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $ 3(_ (T
APPLICANT
SIGNATURE:
.l_ — DATE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675