1994, 08-15 Permit App: 94007898 Plumbing Reversal4
SEWER CONNECTION PERMIT APPLICATION FORM
(11-t 7s47
a' -i5 -qA6
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED. q4'_
(IF KNOWN) Pie
JOB ADDRESS: �7 S
7 , a/ -47l.) PARCEL NUMBER:
CITY :10D TTi JJE ( STATE:
OWNER NAME: s frTv, //f� LL
CITY : ��!'') '� /iJE STATE: C4J/4• Z I P CODE:
ZIP CODE:
ADDRESS:
PHONE NUMBER:4110
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE ONE
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIRREMENTS BEFORE PERMIT IS ISSUED.
ST
CONTRACTOR: . C.� 304$1/_577 ' ADDRESS:
CITY:
PHONE NUMBER:
STATE CONTRACTORS LICENSE NUMBER:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? NO (CIRCLE ONE)
INTERIOR ALTERATION BY: St-EA)/97
ADDRESS: PHONE NUMBER:
CITY: STATE: ZIP CODE:
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 = 5D,e? L7
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS / X 35.00 = . O eD
TOTAL PERMIT FEE DUE $ g vim.
APPLICANT
SIGNATURE:
DATE g-/- 952
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675