1994, 09-30 Permit App: 94009656 Sewerct(4-5-(A13
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT JWILL NOT BE ISSUED.
JOB ADDRESS: Al ` 114)5 Mo1ceow C -`t
(IF KNOWN)
PARCEL NUMBER:
CITY: S-13(>
n/� STATE: WA ZIP CODE:
OWNER NAME: / n/�� R'(UL 4SOESif}S ADDRESS:
CITY: STATE: ZIP CODE:
PHONE NUMBER:
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: 2060er A Lo 34 ADDRESS: 5- 94 / S SAND S
CITY: OAS g'crieb STATE: (-BIW
PHONE NUMBER: 92`z- 45n -
ZIP CODE: 99034
STATE CONTRACTORS LICENSE NUMBER: Lo A )6 A z4.6 g3
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS?
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 =
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $
APPLICANT_ ,-O
SIGNATURE: ((// �O
DATE: �/�Jv � g4/
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675