1994, 02-23 Permit App: 94001468 Sewerdoer
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.
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(IF KNOWN)
JOB ADDRESS: S 3�ao. Wn `- PARCEL NUMBER:
CITY: 5e91Ca.n
STATE= t.C)C� ZIP CODE: ! %c16
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OWNER NAME: c lr rr r O �CN ADDRESS: /71 e -
STATE = PHONE: �J0q) 9� -7-�
CITY = a
PROPERTY OWNER PERFORMING SEWER CONNECTION. INSTALLATION?
NO
CLE ONE)
*IF PROPERTY OWNER ISEWER, THEY MUST NSTALLING
BEFOREIRST PERMITNISCT THE ISSUEL0. TILITIES
DEPARTMENT FOR CONSTRUCTION
CONTRACTOR=
CITY:
ADDRESS:
STATE= PHONE:
STATE CONTRACTORS LICENSE NUMBER..:
UTILIT]ES INSTALLERS PERMIT NUMBER=
INTERIOR PLUMBING ALTERATIONS? YES N0)
CIRCLE ONE)
INTERIOR ALTERATION WORK BY..:
ADDRESS: PHONE=
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 1 X 50.00 = -5000
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $ -50.6r0
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APPLICANT
SIGNATURE
(ItAl
SPOKijE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675