1994, 03-03 Permit App: 94001700 Sewer Gr4tom
SEWER CONNECTION PERMIT APPLICATION FORM 9-4,5
j l ,5
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS : \ ��, \�r A\ PARCEL KNOWN)
JOB
CITY9,VrU, ATE: �� � ZIP CODE: `1� �?1)
OWNER NAME. V = ',; o ADDRESS : A� � \ -
CITY: Vic V'�(snct STATE: 3,_\) ZIP CODE: 1 I;� �;1r!
PHONE NUMBER: l
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: ‘ ( 10 A(k r \C1A,. ADDRESS :
CITY: STATE: ZIP CODE:
PHONE NUMBER:
STATE CONTRACTORS LICENSE NUMBER:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NOS (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 $ 50, E
APPLICANT %J\ • % DATE: -ac--1-
SIGNATURE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675