1994, 08-18 Permit App: 94008036 SewerSEWER CONNECTION PERMIT
*THIS APPLICATION FORM MUST BE FILLED OUT
SIGNED OR PERMIT WILL NOTBE ISSUED.
4c/(_e, JOB ADDRESS : D 3 9 [J/
CITY:_STATE:
OWNER NAME: w G // / a
q a
APPLICATION FORM
ACCURATELY AND IN ITS ENTIRETY AND
(IF KNOWN)
PARCEL NUMBER:
•ZIP CODE:
ADDRESS:
CITY: STATE:
PHONE NUMBER: (oZ b —715/0
'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:
on ADDRESS:
CITY: i2v�12I STATE: 1,./VA
PHONE
/Jj-
PHONE NUMBER: 15r9 - Ct3, S -- q 1-'I
STATE CONTRACTORS LICENSE NUMBER:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES
INTERIOR ALTERATION BY:
ADDRESS:
CITY:
Qty .P c _ Br!
ZIP CODE:
(CIRCLE ONE)
PHONE NUMBER:
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:
S�"=v
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675