1994, 08-16 Permit App: 94007931 Sewer 114 of i
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: S /16 7-- 6 � -e� PARCEL NUMBER: 3 j 2, C)-/N
CITY: STATE: (/ /J/�- ZIP CODE: 7 2 1 Z
OWNER NAME:
" " `� ADDRESS : 5 /6 73""- -/t- Ly
CITY: -7/L69-1A-a4-1 STATE: (A-4- ZIP CODE: 7 9 Z/
PHONE NUMBER: 3 `( --)-- -2- C1 3
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE ON 1Q
ICI
PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: f-f (Sc6, ADDRESS :
CITY: ;---)/1--4A STATE: u-41-
ZIP CODE:
PHONE NUMBER: F5' LI
STATE CONTRACTORS LICENSE NUMBER:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES 1 (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
SIGNATURE: DATE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675