1994, 02-17 Permit App: 94001267 Sewer14521 i 533
]'iL1at63 ZpU
.B/p SEWER CONNECTION
510
PERMIT APPLICATION FORM 471V.5 - Ls?
AND IN ITS ENTIRETY
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS:
CITY: '.----5;XL-6/ •
OWNER NAME: /l/7�(J LS
CITY: .
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(YISCLE
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMITIIS ISSUED.
CONTRACTOR: CAuRCHRINC EX�V%}110 ADDRESS: E 1�ol�bay�� lnF��y€
2_1Po9037 PHONE: QatB5
CociaCC'k 1R-7
STATE: 621/ZIP CODE:
\\\\ADDRESSS: < e //9
STATE: (ie.. -42
(IF KNOWN)
PARCEL NUMBER:
PHONE: 9 ` ✓c97 g02_)
S'TA TE CONTRACTORZ LICENSE Ni IMRER .. :
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS?
INTERIOR ALTERATION WORK BY..:
ADDRESS:
CITY:
STATE:
(CIRCLE ONE)
PHONE:
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 $ ;CY '
APPLICANT
SIGNATURE
ga_c2A-
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675