1994, 10-04 Permit App: 94009402 SewerSEWER
*THIS APPLICATION FORM
SIGNED OR PERMIT WILL
CONNECTION PERMIT APPLICATION FORM
q�- ailoz
MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
NOT BESUED.
(IF KNOWN)
JOB ADDRESS: `���// a,3 6 5 ( J h r_" PARCEL NUMBER:
ZIP CODE:
CITY:
OWNER NAME:
CITY:
PHONE NUMBER:
STATE:
9,:z V ‘/
ADDRESS:
ZIP CODE:
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: AC-M4-{-nocsDrv,4-(- Ltaip nADDRESS:
CITY: (5e0Kaf1i. STATE: 1VA ZIP CODE:
-PD ipx- 1142_,A2
PHONE NUMBER: CI Z.gj • O,55G
STATE CONTRACTORS LICENSE NUMBER: AA M S r G 1c12_1.1
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION BY: -Rc, 'C + J4,v\3r'r\ (A 0 8 P b5 13 I )
ADDRESS: I15?,O L% • nth
CITY :tLre-5
PHONE NUMBER: gal- 4/C NE3
STATE: 1461 ZIP CODE: q96-11..
*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:
eg 4(7
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675