1994, 03-04 Permit App: 94001709 Plumbing ReversalDia orcho-rd
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.
(IF KNOWN)
JOB ADDRESS: IOr1 I y-kZ
PARCEL NUMBER:-�,�Z-1
CITY: STATE:_ ZIP CODE:
aQ2o(o
OWNER NAME: r 0151-Dn __ ADDRESS: IOq l 4i' L
CITY: �<.DC240 0 STATE: SntA C) (o PHONE: a Q,lnJ L,
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
( CIRCLE
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUECI.
CONTRACTOR: �d A ADDRESS:
C I TY: Fj STATE PHONE:
STATE CONTRACTORS LICENSE NUMBER..:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS?
INTERIOR ALTERATION WORK BY..:
ADDRESS:
CITY:
( CIRCLE ONE)
PHONE:
STATE: ZIP CODE:
*ONE �PERMIT 'REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC
THAT WILL BE CONNECTED TO THE SEWER.
SEWER CONNECTION .............: # OF BUILDINGS L_ X 50.00
! X 35 .00
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS
.*TOTAL PERMIT FEE DUE s
APPLICANT
SIGNATURE
SPO ANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675