1994, 06-28 Permit App: 94006024 Sewer , ) re — qhs — 729
SEWER CONNECTION .PERMIT APPLICATION FORM q
q1- G70
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
%h (IF KNOWN) _
JOB ADDRESS: 73 7/ 7 9- �,E. PARCEL NUMBER: 0?.2� `1(71 - O/o6
CITY: Sfen,c) . STATE: ZIP CODE: .9 -2/
OWNER NAME: J4.eP '7 J . ADDRESS : l3 1/7 y ��.
CITY: �po /< //.J +2 STATE: CJ•4- ZIP CODE: 62214,
PHONE NUMBER: �72.-- ;76Y,7
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? � NO
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: ADDRESS :
CITY : STATE: ZIP CODE:
PHONE NUMBER:
STATE CONTRACTORS LICENSE NUMBER:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? ES NO (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS: PHONE NUMBER:
CITY: STATE: ZIP CODE:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDIN?, 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: C77(-4-1Ad- DATE: /7)e
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675