1993, 10-01 Permit App: 93009224 Sewer r q z
'13 - (17
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 .
n
( IF
KNOWN )
JOB ADDRESS: /P, Mil
z. PARCEL NUMBER:
CITY: pc Kcernsz _ STATE: L ZIP CODE: oi-ao(c,
OWNER NAME: �`k 5 170 r ADDRESS: L 09 l f 9
CITY: ,S >//5- /Z/L STATE: 0)/9 PHONE: (7 �lS
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? 40101 NO
CLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: ADDRESS:
CITY: STATE: PHONE:
STATE CONTRACTORS LICENSE NUMBER . . :
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (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 = O 00
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 =
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE /G2A7
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675