1994, 03-25 Permit App: 94002436 SewerSEWER CONNECTION PERMIT APPLICATION FORM
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*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUE'.
(IF KNOWN)
JOB ADDRESS: ��/�t� PARCEL NUMBER:
CITY: ✓�� l7STATE: a/q'/ ZIP CODE: 9�e�
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OWNER NAME : -��
ADDRESS:
CITY: STATE: ZIP CODE:
PHONE NUMBER: 9A ‘7-
PROPERTY
7-PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR:t -iYr)r1� CD(*)S4-(A(4ior ADDRESS: -p o. & c_ 142 3 2.
CITY: L Dn4.4 ani STATE: 4JAr ZIP CODE: q q 2J1 -4 -
PHONE NUMBER: 12 a • O 5S
STATE CONTRACTORS LICENSE NUMBER: A A M S -1--"c...-)(c- 1G z- of i.
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES O (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