1994, 08-22 Permit App: 94008122 SewerSEWER CONNECTION PERMIT APPLICATION FORM (t4- � /L
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISS ED.
�j - (IF KNOWN)
JOB ADDRESS: .-5 /&9 /t7 �/LI Q-llF? PARCEL NUMBER:
CITY: 1/// STATE: /L --- ZIP CODE: y / _
OWNER NAME: � " o 1 iGLLC� ADDRESS: `.2.1132"46/ ()(tom �-I�7-020D
CITY: 41-e STATE: ZIP CODE:
PHONE NUMBER: tel` 4.-V/ ,
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION?. YES
(CIRCLE
qgZ3
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: COut (rhalul e- EKrreNiCi + on
ADDRESS :11'14'(27 E, Val l ei t fr./ Ave
CITY: VP rrirlrAv_ STATE: WA- ZIP CODE: CI g03'7
PHONE NUMBER: q Z4 - 514S�
STATE CONTRACTORS LICENSE NUMBER: Of, uAC,C_44* 1431R,rI
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRC N)
INTERIOR ALTERATIONRA/BY: / l//�f %L (' !iy��> l/ j��
ADDRESS: // / / C`/ ' PHONE NUMBER: �� /j
CITY:�Pe/iL&tet. STATE: !L-.C•C c 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 = d1 D G
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS / X 35.00 =
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE:
�� -- C�i;Le---
DATE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675