1994, 09-14 Permit App: 94008980 SewerSEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN
SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS: S y0/ '7 (.30,962r7,C`FE
CITY: �f7� ItQ ,-. -C_
OWNER NAME: -J/04 4Ln
CITY:
STATE:
STATE:
PHONE NUMBER: l 2-2- -035-3
ITS ENTIRETY AND
(IF KNOWN)
PARCEL NUMBER:
ZIP CODE: FZO
ADDRESS:
ZIP CODE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCL
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: O �/%» ck !� / Iv- ADDRESS ?1:71g2;5( 9r7 5
CITY: 0 i(.,}-f�('�.� /1
PHONE NUMBER:
STATE: ZIP CODE:
STATE CONTRACTORS LICENSE NUMBER: DY &l.rI E 0 cf Q 3
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES cCIRCLE 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 =
TS -AL FEE DUE $
APPLICANT
SIGNATURE:
Or
A -SI - , __ i tlet -.:1.,a, -4./1.2' TE : d> lior
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675