1994, 03-04 Permit App: 94001704 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 ISSUED.
//,,.. (IF KNOWN)
JOB ADDRESS : 39`SUJ �?.PARCEL NUMBER:
CITY: b STATE:
OWNER NAME: �S2)
ZIP CODE: o%/,ei'F/
ADDRESS:
CITY: STATE: ZIP CODE:
PHONE NUMBER: ?-17/-1_57
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE 0 )
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: 14 5 Ct)(1S`%,(" cAC -Ft an ADDRESS: 11E;11
CITY: ISPO ei STATE: W,4 ZIP CODE:
PHONE NUMBER: q 2J - S a L 1-1'
STATE CONTRACTORS LICENSE NUMBER: J -i'. (C) 1 -ki
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS:
CITY: STATE: ZIP CODE:
PHONE NUMBER:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUIT.,DING, SHOP, GARAGE, ETC. THAT WILL
BE CONNECTED TO THE SEWER.
SEWER CONNECTION •# OF BUILDINGS f X 50.00 = S�
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $ S %/
APPLICANT
SIGNATURE:
DATE: ---/54A2/
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675