1994, 02-22 Permit App: 94001373 Sewerti5 x -'12 --
IA V
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
( IF KNOWN)
`nom 1 �^
JOB ADDRESS: 1 d S �` �" (; �'�' ` �{ , R t PARCEL NUMBER:
STATE: i* •
CITY
OWNER NAME: 3bL 3 \) E RAJ
‘) 4'`c--111 ES/STATE;
CIT
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(YISCLE 0
ADDRESS:
ZIP CODE:
*IF PROPERTY OWNER
INSTALLING
REQUIREMENTS BEFOREFIRST
PERMICONTACT
ISSUEDUTILITIES
DEPARTMENT FOR CONSTRUCTION
E. 138110 12th AVE
CONTRACTOR: T�-C a NST eucr (oN ADDRESS:
ZIP G�c}a 1(0
CITY: 5470VcANSF. LOA E=
PHONE: Ga7
STATE CONTRACTORS LICENSE NUMBER..: -TLCCO At* is° 70,1(p
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY..:
ADDRESS: PHONE:
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 =,�i ) 00
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 =35.aC)
TOTAL PERMIT FEE DUE SCKS
APPLICANT
SIGNATURE C
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675