1994, 02-02 Permit App: 94000829 Sewer q(7-5D2
SEWER 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: 3q2-coS S` Nr� ^' PARCEL NUMBER:
CITY: S'fv"'J STATE: ZIP CODE:
� PA- r) ADDRESS: —
OWNER NAME: 1 �u� ( `�'
CITY: STATE:
PHONE: . 1-2-b -2-C"
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE ONE)
*IF PROPERTY OWNER ISEWER, THEY MUST NSTALLING
BEFOREIRST PERMITNISCT THE ISSUEQ.TILITIES
DEPARTMENT FOR CONSTRUCTION
CONTRACTOR= -/
es� ADDRESS: 7 -3I(-7 C 13 ')" -R1
CITY:
mak"ti� STATE: PHONE:
�' •
STATE CONTRACTORS LICENSE NUMBER. . :
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES () (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 I tom' `'
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675