1994, 03-10 Permit App: 94001953 Sewer145 n3. 2 lI
I-I,(65-ke%
SEWER CONNECTION PERMIT APPLICATION FORM
qL/ c153
JOB ADDRESS:
CITY:
OWNER NAME:
CITY:
Lit 432-
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
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PHONE NUMBER:
STATE :
(IF KNOWN)
PARCEL NUMBER:
ZIP CODE: f�
ADDRESS:
STATE: ZIP CODE:
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: f ^S`{e�} Y�� } �7,�C.-f r) ,�-(N(=I'10. 1 ADDRESS: -PO . PXDX-
CITY: Sr-)-k, `J STATE: VJA- ZIP CODE: qc 2J 4-
PHONE NUMBER: 1 2
STATE CONTRACTORS LICENSE NUMBER: AAt•A Ci 161Z.14 i
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES (IQD� (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS:
CITY:
STATE:
PHONE NUMBER:
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 $
s �l
APPLICANT
SIGNATURE:;
DATE : ,7
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675