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1994, 06-07 Permit App: 94005189 Sewer
SEWER CONNECTION PERMIT APPLICATION FORM *THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY SIGNED OR PERMIT WILL NOT BE ISSUED. (IF KN JOB ADDRESS: //46/ 5r O'/. '/- PARCEL CITY: s/©p /f/67/;03:// 7'if/, g/1944/,2740 j4 STATE: OWNER NAME: ( /;/3a � 3 g4/te/7 AND IN ITS ENTIRETY AND OWN) NUMBER: / �'S��/3 ` 29.24? IP CODE: CITY: STATE: PHONE NUMBER: 07S� ADDRESS: /-!-/:?e07 ZIP CODE: (er'J7 >"x7 PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES N9/ (CIRCLE ONE) *IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED. /�/ ( S V '// 7 ADDRESS:/ice CITY: � STATE: ��/C Z I P CODE: ) PHONE NUMBER: 7 l c% STATE CONTRACTORS LICENSE NUMBER: T3C0)47e09r/ UTILITIES INSTALLERS PERMIT NUMBER: INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE) INTERIOR ALTERATION BY: ADDRESS: CITY: STATE: PHONE NUMBER: 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 = 504.' INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00 = TOTAL PERMIT FEE DUE $ APPLICANT SIGNATURE: DATE : p ?/C SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675