1994, 06-13 Permit App: 94005375 Sewer-4154%
0014t)(ZL9°
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT
SIGNED OR PERMIT WILL NOT BE ISSUED.
8 zS S e-Wec4.J
JOB ADDRESS:
CITY: Soke-
STATE: &),e
GU -s37.
9y -s77
ACCURATELY AND IN ITS ENTIRETY AND
(IF KNOWN) _
PARCEL NUMBER: ASS 3,Q/ Flo
ZIP CODE: 5252-0
OWNER NAME: d/y„ jg�y1»P
CITY:
ADDRESS :
STATE: ZIP CODE:
PHONE NUMBER: (7 8 �c3 g- o
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES cALO'
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR(I;
ADDRESS: ) 1 11. /4. MCiimec
CITY: ,Spoit'.co, v-\ 2. STATE : WA ZIP CODE : CI 42.444.
PHONE NUMBER: 0q215 -91W°
STATE CONTRACTORS LICENSE NUMBER: -ro , 571' r 1. -< '" P
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS?,,YES, NO (CIRCLE ONE)
INTERIOR ALTERATION BY: U3�jT tt)..1- tPI r.i h., R//4 j
ADDRESS: PHONE NUMBER:
CITY:
c)J 54 i
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
3 6 --
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00 = r?:3-%
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE:
DATE:
/3 74/
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675