1994, 09-30 Permit App: 94009658 SewerSEWER CONNECTION PERMIT APPLICATION FORM
045 tots
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS: AL AILO 22#2.,w Cr(
CITY:
S Pa
(IF KNOWN)
PARCEL NUMBER:
STATE: Gt-&4 ZIP CODE:
ADDRESS:
STATE: ZIP CODE:
OWNER NAME: 1ALG?L 4 sVa $7-4 5
CITY:
PHONE NUMBER:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE ON
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR:/ / '0 s _r /
4 ' ,04 ADDRESS: " Q`i /S S``�/UDS
`
CITY: �ALC-�/fa�2� STATE: • GVA ZIP CODE: Wo 3C.
PHONE NUMBER: 9124(-4/75'2_
STATE CONTRACTORS LICENSE NUMBER: L-otJ4 * iep 2 4C /CO
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS:
CITY: STATE: ZIP CODE:
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