1994, 03-03 Permit App: 94001681 Sewer - 914- tHf
SEWER CONNECTION PERMIT APPLICATION FORM
9`-j 2_24,
THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
(IF KNOWN)
DB ADDRESS : S 4007 Schafer PARCEL NUMBER:
ITY: Spokane, STATE: WA ZIP CODE: 99206
WNER NAME: Jerome J and Lynn N Nicholls ADDRESS : S 4007' Schafer
ITY: Spokane, STATE: WA ZIP CODE: 99206
HONE NUMBER: 509-974-9745
ROPERTY 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.
ONTRACTOR: A l Jc 6 ADDRESS: -PS). &Y
STATE: Wyk ZIP CODE: g1612-0-4-
HONE NUMBER: c121,— g S n
TATE CONTRACTORS LICENSE NUMBER: A LvJ ArlI A -.' 106, p 5
TILITIES INSTALLERS PERMIT NUMBER:
NTERIOR PLUMBING ALTERATIONS? YES (1-i (CIRCLE ONE)
NTERIOR ALTERATION BY:
.DDRESS : PHONE NUMBER:
;ITY: 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 $ Sze
UPPLICANT
i IGNATURE: DUE, DATE: 2- " y
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675