1994, 03-03 Permit App: 94001667 Sewer _ - (.2 --A,6, 7
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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 � �
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JOB ADDRESS : 0,f ( 2641 yr PARCELOERNUMBER: ( 15�/, /vtD
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CITY: e_, � � STATE: Zv" ZIP CODE: ?-9 4-
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OWNER NAM�• / ,44 �-� b ADDRESS:
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CITY: /y4-4-72.e__ STATE: -2-1J Ce--- ' ZIP CODE:
PHONE NUMBER: 7 - /175
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:( ( R o- ,4-/v6Q ,,0 ADDRESS :
CITY: ( STATE: ZIP CODE:
PHONE NUMBER:
STATE CONTRACTORS LICENSE NUMBER:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS : PHONE NUMBER:
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 -,S IGNATURE: 4'/- ,�_ -7V-4.17' .eir- -d-A DATE: - 3 - 71.
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675