1994, 08-16 Permit App: 94007989 Sewer•
SA -1,e7.1
SEWER CONNECTION -PERMIT APPLICATION FORM q -` 7121
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE SUED. �J /%�j
A/06o �- v (IF KNOWN) Q�- ! "1--10
JOB ADDRESS: /,�'�'/'� �jj PARCEL NUMBER:
CITY: `• STATE: (�('t� ZIP CODE:
•
OWNER NAME: L-eX1 J ADDRESS: /422)4 051—A .
CITY: STATE: ZIP CODE:
PHONE NUMBER: 9c 1 7, -7
PROPERTY OWNER' PERFORMING SEWER CONNECTION INSTALLATION? - YES
(CIRCLE 0
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: Cour(r)r a-Crtr_ EXrrtJ i+ -on ADDRESS: )(,t-1'07 E. 1J2)1.Pr/ JO J /P
CITY: V( STATE: WA' ZIP CODE: 9CIO.i'7
PHONE NUMBER: 124
STATE CONTRACTORS LICENSE NUMBER: CAO I AACC--X- 1 e Sari
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? NO (CIRCLE NE)
INTERIOR ALTERATION BY: t)a/0: ez - ( � ,
ADDRESS: 11/, L��e l'_ / PHONE NUMBER
CITY �i'/ 1/4")-e-41) STATE: a7)1?,‘
ZIP CODE: 9O
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL
BE CONNECTED TO THE SEWER.
SEWER CONNECTION •# OF BUILDINGS A X 50.00 = ) V�
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE:
4'61 J
DATE: 4P11): -----4,K
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE,- SPOKANE, WA. 99260 (509) 456-3675
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