1994, 03-21 Permit App: 94002265 Sewer D SEWER CONNECTION PERMIT APPLICATION FORM g5 tel
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
(IF KNOWN)
JOB ADDRESS:
60 -/c) c)BG/2 L/Al PARCEL NUMBER:
CITY: = -Po '01-�t1Ls STATE: ZIP CODE: (19Z° 6.
OWNER NAME: WAS-_Y VA'JCE ADDRESS:
CITY: • */)0144,t-16 STATE: CA-144ZIP CODE: 99 Z436
PHONE NUMBER: 9 Z e ` 1357
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FORnCONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: o564:7 A �oAJH ADDRESS : gelds Sly/DS
CITY: /R6-6c/1e D STATE: WA ZIP CODE: 99®36
PHONE NUMBER: 92 / - Y/782
STATE CONTRACTORS LICENSE NUMBER: L4""J4ik14 f d
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES 0 (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 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 . 00 =
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE:
a DATE:-/701 04 ea
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675