1994, 05-10 Permit App: 94004155 SewerSEWER CONNECTION PERMIT APPLICATION FORM
5®j
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
(IF JOB ADDRESS: 36//) . LC)DQ4 rLk-(4-C-±-PARCELOWN) NUMBER:
CITY: 3p()kA }lSTATE: LL)A ZIP CODE: ' 9 / R.
OWNER NAME : 1 ► (m A-0 j n-- �-! I �2 . (2 22:6- u aC-1-
9 ADDRESS :
CITY: ) J()/ 3. )J.4) STATE: (,U v ZIP CODE: ' 1 D / 1,-LPHONE NUMBER: q cf 01j 0
PROPERTY 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.
CONTRACTOR: Z--12)e-s-1- i'0li-A-{ u r -or ADDRESS: 7€ sBrbG r.I-u1Gt›./
CITY: �,f�n. �,lll STATE: WA ZIP CODE: qC7 I
PHONE NUMBER: F 9 j - q�
STATE CONTRACTORS LICENSE NUMBER: Z p ,S r _ 91 AH
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS:
CITY:
PHONE NUMBER:
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 = 5-7) (T?
INTERIOR PLUMBING ALTERATIONS:'# OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $ C%, (rt
APPLICANT
SIGNATURE: 7/ �
DATE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675