1994, 07-25 Permit App: 94006962 SewerSEWER
*THIS APPLICATION FORM
SIGNED OR PERMIT WILL
JOB ADDRESS:
CONNECTION PERMIT APPLICATION FORM
MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
NOT BE ISSUED.
(IF KNOWN)
6-'(--S-C) 2 PARCEL NUMBER:
CITY: � STATE: /d?. ZIP CODE:
OWNER NAME: /4 46941,/ �..C44.n4/ ADDRESS:
CITY: STATE: ZIP CODE:
PHONE NUMBER: 9,2d ?`lP
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES (NO)
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: 14 Co rLS--hc n G,f e
CITY : L5100.g4f1Q , STATE :
PHONE NUMBER: Ci 217 - S Q (o
STATE CONTRACTORS LICENSE NUMBER: 1-i'S C (7 n) A- 4E. (2.-3 -k f
ADDRESS:
WA
1J8)1
ZIP CODE: g g 2,12/
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES(:;;) (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:
DATE: ):/c)7/l%
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675