1994, 03-31 Permit App: 94002663 Sewer. 3.3° q� nn--
viikrSEWER CONNECTION PERMIT APPLICATION FORM -! -4 "//
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS: C. c21/' 412P4,,
(IF KNOWN)
PARCEL NUMBER:
CITY: pp STATE: /)q- ZIP CODE: 9,9d0‘OWNER NAME: y46 //jj (/ ADDRESS:
CITY: �/ ((// STATE: ZIP CODE:
PHONE NUMBER: 9B%�iP/a-f
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES 00
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: IA E S (tnncAl t A G 4- C
ADDRESS: I I g I t'. Ya I )tyAin /
CITY: L56cW,Alw.. STATE: \;IA ZIP CODE: ggzbt,
PHONE NUMBER: q %.!o - , G (g91-4-
STATE
oSTATE CONTRACTORS LICENSE NUMBER: N SC( -3n/ dE I Z ?.i Wf
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS: PHONE NUMBER:
CITY: STATE: 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 = `S'O
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE:
DATE : g��ri
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675