1994, 05-19 Permit App: 94004531 SewerSEWER CONNECTION PERMIT APPLICATION FORM q �1 __C �8
*THIS APPLICATION FORM
MUST BE
FILLED OUT ACCURATELY AND IN ITS
ENTIRETY AND
SIGNED OR PERMIT WILL
NOT BE
ISS.
(IF KNOWN)
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JOB ADDRESS: -Z 2
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PARCEL NUMBER:
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STAT �[-Z.
ZIP CODE:
CITY:_
OWNER NAME: V/l'�a-�
ADDRESS: -
CITY:
STATE:
ZIP CODE:
PHONE NUMBER: �i -���
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.
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT ,1FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: YT,C.Me Cpnq tons+nni: Finn ADDRESS: D� �X 1�-i2�2
CITY: �Qo4a o0 STATE: ti/Q- ZIP CODE: UG LL
PHONE NUMBER: V F� - O 5iS 4
STATE CONTRACTORS LICENSE NUMBER: A ,- f 1A 2.IJ 1
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS?
INTERIOR ALTERATION BY
ADDRESS:
�j�
CITY:
YES
NO (CIRCLE ONE)
PHONE NUMBER:
STATE: ZIP CODE: KfLal
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL
BE CONNECTED TO THE SEWER.
SEWER CONNECTION ............:# OF BUILDINGS X 50.00 = S
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE: DATE:
DATE•
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675