1994, 08-08 Permit App: 94007540 Sewer /4 ea+ktr 1OQrt
SEWER CONNECTION PERMIT APPLICATION FORMED
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
/ -1 (IF KNOWN)
JOB ADDRESS: .may / &Ldp' / — PARCEL NUMBER: �}
CITY: STATE: �/�(• ZIP CODE: 9YoZaZ
OWNER NAME: /1 /-j'P4/ ADDRESS:
CITY: STATE: ZIP CODE:
PHONE NUMBER:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: ■ s • ■ r ADDRESS : / 1S11
CITY: Lseo / STATE: \A/, ZIP CODE: gcf2,,r Ia
PHONE NUMBER: 9 2 - c( �
STATE CONTRACTORS LICENSE NUMBER: N'S((�&] 12_3 4LI
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.
00
SEWER CONNECTION • # OF BUILDINGS / X 50 . 00 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS
TOTALERMIT FEE 3DUE 5 . 00 $ S/
AIGNITUE J (
SIGNATURRE: / i �% DATE: /Y/
��i�2GP�/ /� ./1
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675