1994, 11-08 Permit App: 94011186 Sewer frAA Id
ILLS /
SEWER CONNECTION PERMIT
APPLICATION FORM
PLEASE NOTE: This application form must be filled out accurately and in its entirety, and signed,
or a permit will not be issued.
PROJECT INFORMATION
Job address: Owner's name:
S /G Z v t c-,,.,�, ,-- /I 6/7,/z-,
City: Au-t.. City/State:
Zip: 9 9 Z Z Zip:
/
Parcel number (if known): Phone: r
WILL THE PROPERTY OWNER BE PERFORMING THE SEWER CONNECTION
INSTALLATION?* Yes No
*If property owner is installing the sewer connection, they must first contact the UTILITIES DEPARTMENT for construction
requirements before the permit is issued.
CONTRACTOR INFORMATION
Contractor (company name): State contractor license number:
AtI vNical S A cki v:e. A L‘A/A V A - JO P 5
Business address: Utilities installers permit number:
PO 60)L 10 16 Ce,2,
City/State: .,S0p,Kr .g. WA
Zip: 9j c ZI i..4 Phone: Go.2 - B 5 or)
INTERIOR PLUMBING ALTERATIONSLT— (if applicable)**
Contractor (if different From -h�nCF,','� P11^1?P' _ I
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Business Address/ City/State/Zip:p
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** For plumbing reversal fee information, see reverse side of this form.
FEE INFORMATION
Sewer Connection: Number of Buildings / X (times) $50 (per bldg) = $ e'! 3-73
TOTAL FEE
(One permit required for each separate building, shop,garage, e. that will be connected to the sewer)
APPLICANT SIGNATURE: 7 ' i - Date: /- / y y"
Spokane County Division of Buildings
West 1026 Broadway Avenue * Spokane, Washington 99260 * (509) 456-3675