1993, 08-12 Permit App: 93006989 Sewer 65e7
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: fd ;"V
,417 PARCEL NUMBER:
CITY: of STATE: /A.A ZIP CODE: q9 // t
OWNER NAME: Jc/ S .i n e ADDRESS: r j 3 3 PI
CITY: 5,D040,4
STATE: (AA- PHONE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? ar NO
( CIRCLE ONE)
*IF PROPERTY OWNER INGSEWER , THEY MUST REQUIREMENTS BEFOREIRST PERMIOTNISCT THE ISSUED .TILITIES
DEPARTMENT FOR CONSTRUCTION
CONTRACTOR: ADDRESS:
CITY: STATE: PHONE:
STATE CONTRACTORS LICENSE NUMBER . . :
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES V (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 / X 50 .00 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $
APPLICANT /
SIGNATURE / /
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509)456-3675