1994, 08-08 Permit App: 94007538 SewerSEWER CONNECTION PERMIT APPLICATION FORM q -1,5 3S
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
TOB ADDRESS:
CITY:
OWNER NAME:
(IF KNOWN)
PARCEL NUMBER:
ZIP CODE:
ADDRESS:
CITY: STATE: ZIP CODE:
PHONE NUMBER:- c/ 8L'D
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 ISSUED.
CONTRACTOR: '%�aJ ADDRESS:
CITY: l� STATE: 1.✓G ZIP CODE:
PHONE NUMBER:
STATE CONTRACTORS LICENSE NUMBER
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO CIRCLE ONE)
INTERIOR ALTERATION BY
ADDRESS:
PHONE NUMBER
CITY: _SW.Vf-E: 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 =
X 35.INTERIOR PLUMBING ALTERATIONS: TOTALNGS PERMIT FEE DUE O $
APPLICANT
SIGNATURE:
DATE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 102 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675