1994, 02-14 Permit App: 94001127 Sewer .. $4-- -1 iLl
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SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY n
AND SIGNED OR PERMIT WILL NOT BE ISSUED .
( IF KNOWN)
IO_* PARCEL NUMBER:
JOB ADDRESS: 3 �9 ��
' :— ZIP CODE= ^
CITY- � STATE
--�
OWNER NAME= O ADDRESS:
CITY= Gnn " "' °
STATE=11— PHONE=
PERFORMING SEWER CONNECTION_INSTALLATION? YES NO
PROPERTY OWNER (CIRCLE )
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACTIS THE
UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE
i.
CONTRACTOR= ° '12 ` "i n ADDRESS:
ST AT.E:�LL�.
PHONE: 1 �a G a 4 q
CITY= 1cj2t2 !
STATE CONTRACTORS LICENSE NUMBER. . :
UTILITIES INSTALLERS PERMIT NUMBER=
INTERIOR PLUMBING ALTERATIONS? YES
NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY. . :
PHONE=
. ADDRESS=
STATE: , ZIP CODE=
CITY= '
*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 /
�/ //('
iii/i/ �'
SIGNATURE �d�' ,gr
SPOKANE COUNTY DE• RTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509 )456-3675