1993, 10-15 Permit App: 93009855 Sewer-)W\
PP'
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.
JOB ADDRESS: 3D5 ` \rt SA -
CITY:
OWNER NAME:
CITY:
STATE: 1I✓ \
(IF KNOWN)
PARCEL NUMBER:/16),501 // --
ZIP CODE: 1�1.0
C- ADDRESS:
STATE: PHONE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED,.
CONTRACTOR: ADDRESS:
CITY: STATE: PHONE:
STATE CONTRACTORS LICENSE NUMBER..:
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.
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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