1994, 10-25 Permit App: 94010648 Sewer 100421
SEWER
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SEWER CONNECT
ION PERMIT V
APPLICATION FORM
PLEASE NOTE: This application form must be filled out accurately and in its entirety, and signed,
or a permit will not be issued.
PROJECT INFORMATION
Job address: Owner's name:
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City: �l�'! � / City/State: _ , „, j 2,fia r
Zip: 'f % > Zip: , 19_.
Parcel number (if known): Phone: �}
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... WILL THE PROPERTY OWNER BE PERFORMING THE SEWER CONNECTION
INSTALLATION?* Yes �No
*If property owner is installing the sewer connection, they must first contact the UTILITIES DEPARTMENT for construction
requirements before the permit is issued.
CONTRACTOR INFORMATION
Contractor (company name): State contractor license number:
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Business address: Utilities installers permit number:
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City/State: r-nIVA
Zip: q q 2 0, Phone: ci - Bq („14
INTERIOR PLUMBING ALTERATIONS (if applicable)**
Contractor (if different from above): Phone:
Business Address: City/State/Zip:
** For plumbing reversal fee information, see reverse side of this form.
FEE INFORMATION
Sewer Connection: Number of Buildings X (times) $50 (per bldg) _ $
TOTAL FEE
(One permit required for each separate building, shop,garage, etc., that will be connected to the sewer)
APPLICANT SIGNATURE: (II'
/Ii� /�, u/i4 Date: //,:3? 9/
Spokane County Division of Buildings
West 1026 Broadway Avenue * Spokane, Washington 99260 * (509) 456-3675