1994, 09-27 Permit App: 94009539 Sewer�L(5-i00
SEWER CONNECTION PERMIT APPLICATION FORM 9 q 95"3,
*T{{IS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED. v/i'
(IF KNOWN) `5sj2� 2
JOB ADDRESS: [/s"94' `4<57a»�n", PARCEL NUMBER: ( 51:3 ! (lett
STATE: Lt/� ZIP CODE: 9%�,Q%� Q
CI`PY: �YGC7J A74,..e/!
OWNER NAME: l�Ol9/'/;L�.C2-/i) P
CITY: .r7 [G.p) t STATE: 6,c)/¢ ZIP CODE: f9c'0 (o
PHONE NUMBER: / - 2 n
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE £,
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR COONSTRU�CITION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: 0 Celt L.67,0 e ADDRESS: A> ( a V- VI /j)47
CITY: _" I4i .64_)$k STATE: ZIP CODE: .F9 O'S
/
PHONE NUMBER: f7;71
STATE CONTRACTORS LICENSE NUMBER:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES O (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS:
CITY: STATE: ZIP CODE:
ADDRESS: /v'4,7d VN/de✓si4.
PHONE NUMBER:
*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:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675