1995, 03-28 Permit App: 95001812 Sewer SEWER CONNECTION PERMIT
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:
City: City/State:
Zip: Zip:
Parcel number (if known): Phone:
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:
14 4 S Co(lc c+,'on N S an 123.k.F
Business address: Utilities installers permit number:
City/State: AS 4 k r\F k A
Zip: q g 2 D �c Phone: G - S G c„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: Date:
Spokane County Division of Buildings
West 1026 Broadway Avenue * Spokane, Washington 99260 * (509) 456-3675