1994, 06-02 Permit App: 94005021 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.
JOB ADDRESS: I`/ 7 �, aX4P1 (IF KNOWN)
PARCEL NUMBER:
CITY: C;1-/ STATE: 64 ZIP CODE:
OWNER NAME: ,% ADDRESS:
CITY: .. r q („eit.c.,(L...- STATE: 4,4) ZIP CODE:
PHONE NUMBER: 1.2), -“7V
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES 40
(CIRCLE ON
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR C ST UCTION REQREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: /42.1 _ 11d UIADDRESS : f.o . Bhix ill b
4,
CITY: 5 d STATE:W . ZIP CODE: /144 I/
PHONE NUMBER: 9 ''1 - 1049135
STATE CONTRACTORS LICENSE NUMBER: f i"� OL e. 1 v Sle / •�1
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 $
AAAN;-,/v0.0
I
APPLICANT SIGNATURE: DATE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675