1994, 06-13 Permit App: 94005373 Sewer,
cfq-$373 q 41 5 - 6y$
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS O' q/O ir?- rL/CQ- PARCELOWN) NUMBER: 145213. q10€
(IF CITY: $ -"t-- STATE:¢ ZIP CODE: 1 a O -C.
ADDRESS: 5)42:1 -16. --
OWNER NAME: LO40,fib ks4tc-JLe�-
CITY: STATE: ZIP CODE:
PHONE NUMBER:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES 6-;)
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR(
ADDRESS: ) I 1 Z. /4 NI.mer
CITY: .cpdi{p*N e- STATE: WA ZIP CODE: g424a
PHONE NUMBER: C[2 c3 -9114(0
STATE CONTRACTORS LICENSE NUMBER: 7rQ MS -TE "-! 1 41 6/1
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 =
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $
„0
APPLICANT
SIGNATURE:
DATE: 6—/3- Y1./
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675