1994, 07-18 Permit App: 94006679 SewerWok
SEWER CONNECTION PERMIT APPLICATION FORM
911 -//(j
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS: 3 6 (.5 7 s, •' 7 we.�-y
CITY :..-�,!'7,e7/0M/E- STATE:
OWNER NAME: / S S /"l / L j�i�,j)
PHONE NUMBER: 92 e-
STATE : Wl%
(IF KNOWN)
PARCEL NUMBER:
ZIP CODE:
ADDRESS:
ZIP CODE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NC
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: iI. C CpR,S-hrjAr-4-iorl
ADDRESS: 1,3, t L � . I Z Ave.-
CITY:
/e..
CITY : -S nrZlhn n r,- STATE: .JA- ZIP CODE: g ci /A (.
PHONE NUMBER: 9 2..r7 - („ (fin
STATE CONTRACTORS LICENSE NUMBER: 71_, G. C. 0 -X-'Al----- 1 0 1 M fc,
UTILITIES INSTALLERS PERMIT :NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES T)(CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS:
CITY:
PHONE NUMBER:
STATE:
ZIP CODE:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL
BE CONNECTED TO THE SEWER.
SEWER CONNECTION 'it OF BUILDINGS / X 50.00 =,5-0. 00
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $ ` 7 e) /)
APPLICANT
SIGNATURE:0 I /
DATE: 7--/z- z / 5/
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675