1995, 03-13 Permit App: 95001382 Sewer\\)(tvfv/Q,9(191-14
c4SS - I�7
SEWER CONNECTION PERMIT O5 3•3 1 -
APPLICATION FORM
PLEASE NOTE: This application form must be filled out accurately and in its entirety, and signed,
or a permit will not be issued.
PROTECT INFORMATION
Job address:
/3 N Eemil Zit.
Owner's name:
$»i4
City:
City/State: _ - AN,yi J�
Zip: 990W,
Zip: 99 /‘
Parcel number (if known):
Phone:
72 g -5-9«'ij
WILL THE PROPERTY OWNER BE PERFORMING THE SEWER CONNECTION
INSTALLATION?* Yes xNo
If property owner is installing the sewer connection, they must first contact the UTILITIES DEPARTMENT for construction
requirements before the permit is issued.
CONTRACTOR INFORMATION
Contractor (company name):
1-4 4 3 Cons-v'tac+-t'on
State contractor license number:
N_S_Cnk)4(*12.34E
Business address:
I I `31n E• VCL,II.Pq/yJo�
Utilities installers permit number:
City/State: S 0.n y
Zip: G q 2,cA, Phone: G Li_ - 6G cr,t-I-
INTERIOR PLUMBING ALTERATIONS (if applicable)"
Contractor (if different from above): Phone:
Business Address:
City/State/Zip:
** For plumbing reversal fee information, see reverse side of this form.
FEE INFORMATION $
Sewer Connection: Number of Buildings / X (times) $SO (per bldg) = O°
TOTAL FEE
(One permit required for each separate building, shop, garage, etc., that will be connected to the sewer)
APPLICANT SIGNATURE: Date:' -1/1/7 1 /1/7S
nociarean
Spokane County Division of Buildings
West 1026 Broadway Avenue * Spokane, Washington 99260 * (509) 456-3675