1994, 03-09 Permit App: 94001853 Sewer C' E19
SEWER CONNECTION PERMIT APPLICATION FORM
9145 'Zt- q
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
(IF KNOWN)
JOB ADDRESS: P ( 06 (-7,., � PARCEL NUMBER:
CITY: 4,74(Prl'e STATE: ( ! ZIP CODE:
OWNER NAME: T e r'' l t-7(t ADDRESS: `-
CITY: �'� STATE: - ( ZIP CODE:
PHONE NUMBER:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
CIRCLE 0
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: /(, .07-/` yr, c,„A'/ 1117t ADDRESS : (0-C( C'/ o i"' z` r
STATE
CITY: N ZIP CODE: (
CITY: `}���.��
PHONE NUMBER: n7-q- c,;/-0K
STATE CONTRACTORS LICENSE NUMBER:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES INOJ (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 = 5e3, oc)
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS
35. 00
PERMIT FEE
TOTAL
APPLICANT
SIGNATURE �' ' — DATE: X
SPOKANE COUNTY DEPARTMENT OF BUILDINGS 456-3675
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509)
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