1994, 03-10 Permit App: 94001905 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: /J///fI//g F+�.e�"//J PARCEL NUMBER: /I
CITY: STATE:_ ZIP CODE:
OWNER NAME: 9;&4 l s cu ADDRESS:
CITY: STATE: ZIP CODE:
PHONE NUMBER:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE O
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT aF..,,O��R CONSTTeRUCTION REQUIREMENTS BEFORE PERMIT IS/ISSUED.
CONTRACTOR:������1iiiifi/`:�� (1)n iMina� ADDRESS: E.��F
CITY: CU '��• STATE: /A )e. ZIP CODE:�9.�%i lv
PHONE NUMBERR:9:f/n-RY�� ,n
STATE CONTRACTORS LICENSE NUMBER: A,?, 3 ,A -
UTILITIES
INSTALLERS PERMIT NUMBER:
INTERIOR
PLUMBING ALTERATIONS?
YES
NO
(CIRCLE
ONE)
INTERIOR ALTERATION BY:
ADDRESS:
PHONE NUMBER:
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 =
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE: /ir1 .P/ i ✓//'� DATE: �-�.� zez
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675