1994, 10-17 Permit App: 94010260 Sewer?s
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SEWER CONNECTION PERMIT
APPLICATION FORM
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PLEASE NOTE: This application form must be filled out accurately and in its entirety, and signed,
or a permit will not be issued.
PROJECT INFORMATION
Job address:
37. (a s, ntw-- Ro_-)/ ct,
Owner's name:
ERR *ShrAR L3Pit-dups
CityS�o ��,�i
City/State: SrD r6o/,
Zip:
Zip:
City/State: SPQR an en 4JA
Parcel number (if known):
Phone:
WILL THE PROPERTY OWNER BE PERFORMING THE SEWER CONNECTION
INSTALLATION?* Yes k No
*If property owner is installing the sewer connection, they must first?ontact the UTILITIES DEPARTMENT for construction
requirements before the permit is issued.
CONTRACTOR INFORMATION
Contractor (company name):
"-L-C Cons-1-r-LAc4-;on
State contractor license number:
"iLCcG -*k i01 M6
Business address:
13Qr3((o E. 12, -FK _f -.
Utilities installers permit number:
City/State: SPQR an en 4JA
Zip: q q 2,( (o Phone: GI' 21 - (oi
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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) $50 (per bldg) _ $ SO , "—
TOTAL FEE
(One permit required for each separate building, shop, garage, etc., that will be connected to the sewer)
Date: /6 -
APPLICANT SIGNATURE:
Spokane County Division of Buildings
West 1026 Broadway Avenue * Spokane, Washington 99260 * (509) 456-3675