1994, 05-03 Permit App 94003873 SewerSEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN
SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS:
f (IF KNOWN)
/ 9: 'F 2 /.S- �/ r rw��a� ( PARCEL NUMBER:
CITY: j> C7 r�G--2K STATE: A24
OWNER NAME : % J� I h.:- - Nv ✓ct
CITY:
a � 3g'i3
- in5
ITS ENTIRETY AND
6L 3 r J
453.2/, 4103
ZIP CODE: Z-41'76,
ADDRESS: /�' / �- T r`'l
STATE: Z/v/ ZIP CODE: Zci 6
PHONE NUMBER: -
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? EYEY S� NO
TIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: r� 4,1 6= ✓ ADDRESS :
CITY: STATE: ZIP CODE:
PHONE NUMBER:
STATE CONTRACTORS LICENSE NUMBER:
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 = gdb•4Q
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS / X 35.00 =\,.w
TOTAL PERMIT FEE DUE $ ) SA4
APPLICANT
SIGNATURE:
DATE : 3 15-
0
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675