1994, 11-04 Permit App: 94011041 Sewer1
>J %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.
/aWS. Q gy (IF KNOWN)
JOB ADDRESS: PARCELLNUMBER:
CITY: .4.44.9. STATE: iiia. ZIP CODE: 7:9<-7/2s(OWNER NAME I / -/P.4/Lt ) T 61 r I r i ADDRESS:
CITY: STATE: ZIP CODE:
PHONE NUMBER: 9ri2/ d a 9n
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: 5 Cnfl + \
ADDRESS: I I S I l Va. I Lel VJfl 1
CITY: 31OcaC, f\e. STATE: WA' ZIP CODE: gg2,Dl.-. 1
PHONE NUMBER: q ZIe - S 4 L
STATE CONTRACTORS LICENSE NUMBER: I-1-37- 0 / I dE I2 a1 F
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIIO�N�S/? /IES NO (CIRCLE ONE)
INTERIOR ALTERATION BY: i/�' 4� C_�4r /S�� re -6 -rt--
ADDRESS: PHONE NUMBER:
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 =
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS / X 35.00 = —
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE:
DATE: `3/3793'
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675