1994, 01-24 Permit App: 94000564 Sewer4,437.4Y - E;(22/
SEWER CONNECTION PERMIT APPLICATION FORM
KTHIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
JW
(IF KNOWN)
JOB ADDRESS: J 7� y PARCEL NUMBER: `
CITY: ‘ctl-/lDP STATE: //1 7- ZIP CODE: 99of�d.
OWNER NAME:i//n0-i1-&-1 ADDRESS:
CITY: STATE: PHONE: /27, 'OD 5V
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE 0 E)
KIF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE .UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED..
CONTRACTOR: k 4S COR.S+rur lion ADDRESS: 11,611 E. \%0. lep, lam/
CITY: .SpO1Q2J P. STATE: vJA PHONE: Soca - C12./6 - $R6L
clg2p
STATE CONTRACTORS LICENSE NUMBER..: N'S C o N 1-,k 173 44
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS?. NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY..: S 9 (I-y4;C a, ,L2
ADDRESS: PHONE:
CITY: STATE: ZIP CODE:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC
THAT WILL BE CONNECTED TO THE SEWER.
oD
SEWER CONNECTION;,, i :: F Ik OF BUILDINGS /X 50.00 = , IT&
INTERIOR PLUMBING ALTERATIONS: 11 OF BUILDINGS / X 35.00 =
00
TOTAL PERMIT FEE DUE $
APPLICANTr;4.HAT{',
SIGNATURE //L(�/o2-/
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675
C