1994, 06-14 Permit App: 94005534 Sewer SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
7 r� (IF KNOWN)
JOB ADDRESS : /1 22? , ll PARCEL NUMBER:
CITY: She N STATE: frz- (7' ZIP CODE: 2 U 6
OWNER NAME: c�o n/ �� S/9 G ADDRESS: ' 1 2 2 o r. t 7"
CITY: 5/24) /r 4 " j= STATE: ' ZIP CODE: cel/ 2 U C
PHONE NUMBER: 2^ 2- 2- U 11
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? 4010 NO
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: ADDRESS:
CITY: STATE: 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: 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 JJ
SIGNATURE: ✓ ln" Z-- -'' DATE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675