1994, 02-18 Permit App: 94001344 SewerSEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS: J /()
CITY: -.S ''A'A-Q
STATE: /dC? ZIP CODE: 91
9+
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(IF KNOWN)
PARCEL NUMBER:
OWNER NAME: y/Y
CITY:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES6-1°-)
(CIRCLEONE)
STATE:
ADDRESS:
PHONE :
*IF PROPERTY OWNER 'INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED
.
CONTRACTOR: r' S. Cp rk54-i1A r+hnn ADDRESS: 1 8 11 va4 `e:
CITY: -6€0kflil� STATE: WA a 2 PHONE: 5oG - <1.. VGL`-.
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STATE CONTRACTORS LICENSE NUMBER..: 145 Cr) N )4'k 123
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY..:
ADDRESS:
CITY: STATE: ZIP CODE:
PHONE:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC
THAT WILL BE CONNECTED TO THE SEWER.
SEWER CONNECTION - it OF BUILDINGS
X 50.00 =
INTERIOR PLUMBING ALTERATIONS: It OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE
f/f 1 `�
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675