1994, 03-11 Permit App: 94001948 SewerSEWER CONNECTION PERMIT APPLICATION FORM
CP -15 lAep2
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS :00 j f S' - e2 -1Q1
(IF KNOWN)
PARCEL NUMBER:
CITY: t)&,,r,O 7 J t STATE: Vv ZIP CODE: 90 3 7
OWNER NAME : ✓ 7 7r L41 C (/G ,02-54 1i.--1 ( ADDRESS: O / 3 E - - eu<56 Ac lr-1
CITY: i‹.1 i -1 C- STATE: WO ZIP CODE: T 72- 0
PHONE NUMBER: �-f e� -Q 1 q 2_
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE ON
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT I5 ISSUED.
CONTRACTOR: (a® v, o 6==-74 L
ADDRESS: %U /a/2-0 704; '0
CITY: , L. -,o c STATE: (A/A ZIP CODE: ! S a 0 -'
PHONE NUMBER: 99'- -3 Q /3
STATE CONTRACTORS LICENSE NUMBER:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS:
CITY: STATE: ZIP CODE:
PHONE NUMBER:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL
BE CONNECTED TO THE SEWER.
SEWER CONNECTION .# OF BUILDINGS X 50.00 = SO -C10
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $ SUr cA:=1
APPLICANT
SIGNATURE:
DATE: s- - ( ( -9 7
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675