1994, 05-23 Permit App 94004651 Dryline SewerCONTRACTOR:
SEWER CONNECTION PERMIT -APPLICATION FORM
*THIS APPLICATION FORM MUST BE,FILLED OUT ACCURATELY
SIGNED OR PERMIT WILL NOT BFi/ SSUED.
JOB ADDRESS:
CITY:
OWNER
CITY:
PHONE
j77 /kaa‘o
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v( ( STATE:
NAME: ---sl ' L e i)2 4v eb e i2
no' STATE : ` " "'
NUMBER: 92 75-:4t9
(IF KNOWN)
PARCEL NUMBER:
-ti
/ 7
AND IN ITS ENTIRETY AND`
45142 1 Iif/
ZIP CODF7.24;
ADDRESS: 7/33/ 4 /' ` /
ZIP CODE: t7g�1
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTI.N REQUIRgggNTS BEFORE �f IT IS SS �.
/K E5 V •
ADDRESS:
CITY: O Pen STATE
PHONE NUMBER: 'fib 7J 6;)-e)
STATE CONTRACTORS LICENSE NUMBER: L t i N
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS?
INTERIOR ALTERATION BY:
ADDRESS:
ZIP CODE: 9'q2/l
YES ENO (CIRCLE ONE)
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 $
APPLICANT
SIGNATURE:
DATE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675