1994, 03-28 Permit App: 94002490 Plumbing Reversal*THIS APPLICATION
SIGNED OR PERMIT
JOB ADDRESS: S
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SEWER CONNECTION PERMIT APPLICATION FORM
in (crcPp%
FORM MUST BE FILLED
WILL NOT /BE ISSUED.
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STATE : taj AS (4
OWNER NAME: C.l (L/Lci PAS5714026
CITY: t*DO(l444.J6: STATE: t.J 4
PHONE NUMBER:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE 0
CITY: 5cicaoc-t-ree
Roe: 3z(p
gni — vi ci r
OUT ACCURATELY AND IN ITS
ENTIRETY AND
(IF KNOWN)
PARCEL NUMBER:
ZIP CODE:
ADDRESS : 5 — 2-444
R N E 5
ZIP CODE:
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR, CONSTRUCTION REQUIREMENTS BEFORE PERMIT I5 ISSUED.
CONTRACTOR(I A)ni 41/70C, r(J-Kkirl 1'i t1G� ADDRESS: 11 I Z N. M r rne r
CITY: rt A r, STATE: ti/,4 ZIP CODE:
1 •
PHONE NUMBER: G2 C3 -1(71r)
STATE CONTRACTORS LICENSE NUMBER: 77) M S Tom*- 11-I- I M
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS?
NO (CIRCLE ONE)
INTERIOR ALTERATION BY: L7ALz AL.( 1" LC."" --at 1
ADDRESS: PHONE NUMBER:
CITY: cate, E
STATE: k3f 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
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00
IZt0 . " b''- TOTAL PERMIT FEE DUE
00
APPLICAN
SIGNATURE:
DATE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675