1994, 02-14 Permit App: 94001094 Sewer 4 uz,t 0(d r&h 9
en
.6) 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: _ 5 S V hk, PARCEL NUMBER:
ll /flV STATE:_�� - ZIP CODE: 9 9‘21--0
CITY: Sr /j �
OWNER NAME: l- c C� 1- ADDRESS: -<-,2 -� s-" `��
CITY: S �a k /✓L- STATE: / PHONE: 9 - 5_2
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? (CIEljRCLE
NO
ONO)
*IF PROPERTY OWNER INSTALLINGREQUIREMENTS BEFORESEWER, THEY MUST IPERMITNISCISSUEQTHE .7ILITIES
DEPARTMENT FOR CONSTRUCTION
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 a
THAT WILL BE CONNECTED TO THE SEWER.
SEWER CONNECTION : # OF BUILDINGS f X 50.00 = SO•g0
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS
X 35.00 =
TOTAL PERMIT FEE DUE $ •tfX
APPLICANT /
SIGNATURE ,t j
SPeKE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675