1994, 09-12 Permit App: 94008923 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.
c (IF KNOWN)
JOB ADDRESS: /C9O C %D PARCEL NUMBER:
CITY: ��.^'„�. STATE: ZIP CODE: "_-2 t -
OWNER NAME: ^P'-) ”' a rd -qt i , ap') ADDRESS:
CITY:
STATE:
ZIP
CODE:
PHONE NUMBER:
q':�g} "s -7B5
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NF
(CIRCLE 0
+IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: FOrF4's ADDRESS: q'I13 C, 4412
CITY:,4n0 Ckn e_ STATE: ��_ ZIP CODE: a9�D L,
PHONE NUMBER: LI24- - L, 182
STATE CONTRACTORS LICENSE NUMBER: F O 2-L5 Ci d 4 4 C .��
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS:
CITY:
STATE
PHONE NUMBER:
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,
DATE: 9- /2' 9;t -,'-
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675