1994, 04-18 Permit App: 94003268 SewerSEWER CONNECTION PERMIT APPLICATION FORM
(4- 3z_c,$)
Ll 14 0
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS: 363 S. N\ERcy 0 -
CITY : Sro kIN J f= , STATE: W pt • ZIP CODE:
OWNER NAME: K' tJ O/ €,pj A) ADDRESS :
CITY: SPO k/R/// , STATE: tfJM . ZIP CODE: '192 0
PHONE NUMBER : 9 '211( - 05S 7
(IF KNOWN)
PARCEL NUMBER:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES C
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: 1L,..C, CP R,5 -h( M,Lr-kco
ADDRESS:
tavt✓ . L 2 74.\/
CITY: - pc*vi nr, STATE: v./A ZIP CODE: 9
PHONE NUMBER: 9 1,9 - (.,()
STATE CONTRACTORS LICENSE NUMBER: � L G C.. O - ' —', — 10 1 M ip
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES (NO (CIRCLE ONE)
INTERIOR ALTERATION BY:
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 = .50. 00
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $ „S -7).0C)
APPLICANT
SIGNATURE: __29_,4-24%4.-^70,- ,
DATE: 21 �d 9
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675