1993, 08-27 Permit App: 93007594 Sewer . 1 591f
3
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST
NBE FILLED
BE IEDUOUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL
( IF KNOWN)
JOB ADDRESS:
I�, .-� I /`� PARCEL NUMBER: /
-
1
CITY:
STATE: ZIP CODE:
OWNER NAME: ADDRESS:
CITY:
STATE: PHONE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CISCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED .
ids Lam i_)C,-1L ADDRESS
CONTRACTOR:
STATE: / `/
CITY: 4:�
PHONE:
,J
STATE CONTRACTORS LICENSE NUMBER . . : ��f ' rt_
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.
L--
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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