1994, 09-22 Permit App: 94009323 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.
(IF KNOWN)�/
JOB ADDRESS: �U �' I. .� �� 4 14,-f- PARCEL NUMBER: / ')-'Y L, -2z
CITY: 4,;Z,lfa' STATE: %✓ic ZIP CODE:
OWNER NAME: L — Lc 4 o,"5147� ADDRESS•N76Y/ /��ec:faro7 ,�n ip
CITY: i �aHa STATE: ✓/U ZIP CODE:
PHONE NUMBER: ,/.2Z//01�-'/
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION?(-
NSTALLATION?YES NO
IRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: -6
(.✓ vl FU
ADDRESS:
CITY:
STATE:
PHONE NUMBER:
STATE CONTRACTORS LICENSE NUMBER:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? LYE.Si'
INTERIOR ALTERATION BY:
ADDRESS:
CITY
STATE:
ZIP CODE
NO (CIRCLE ONE)
PHONE NUMBER:
ZIP CODE:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL
BE CONNECTED TO THE SEWER.
SEWER CONNECTION ............:H OF BUILDINGS_ X 50.00 =
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE
DATE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675