1994, 03-08 Permit App: 94001678 Plumbing Reversal►]
9+-/c,-77
:f 0/45 ,227
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIR
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
lit -1172
5-2664 (IF KNOWN)
JOB ADDRESS: - P/A/s 5 PARCEL NUMBER:
CITY: Qlyl-. STATE:_- ZIP CODE gGZO()
OWNER NAME= W47AS �`�d
int -€r ADDRESS: SAM
STATE: PHONE: qxr-7.K
CITY:
PROPERTY OWNER PERFORMING. SEWER CONNECTION INSTALLATION? YES NO
(YISCLE ONE)
*IF
DEPARTTMENTPROPERTY
FOROWNER
CONSTRUCTIONINSTALLING
REQUIREMENTS BEFOREFIRST
PERMIOTNISCUTILITIES
ISSUER.
DDRESS= 1 ) 12. ►J, MflJ'ner
•u . a'
CONTRACTOR=
CITY: .SpnKrume-.
STATE: WJf4 PHONE S041 - 417C; /P/ y,n
gCl2l(0
STATE CONTRACTORS LICENSE NUMBER..: 'rQM STF -Y- JL4- f 4K M
UTILITIES INSTALLERS PERMIT NUMBER=
INTERIOR PLUMBING ALTERATIONS?
INTERIOR ALTERATION WORK BY. . a _ki_Pr U -11-6)
ADDRESS: ft -14M
CITY:
NO (CIRCLE ONE)
STATE:
_
PHONE: 7Z� 2-01-17
ZIP CODE:
•
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC
THAT WILL BE CONNECTED TO THE SEWER.
SEWER CONNECTION N OF BUILDINGS X 50.00 =
6-0
INTERIOR PLUMBING ALTERATIONS X 35.00 = SJ.6 0 OF BUILDINGS 9 rixzur
7 oil (-) _Shout r! 2 sinKS TOTAL PERMIT FEE DUE $ / DC
.5 Poo
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675