1994, 08-01 Permit App: 94007219 Sewer6661 1)
7 211 Nd
SEWER CONNECTION PERMIT APPLICATION FORML4. POncb-Ao-dcL2'
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED. f p"�� psiq R'�v�i �7�n L 2- E5 I
Q IF KNOWN) 4(4c8.2(/.
/ j ,, (I
JOB ADDRESS: 7l/O� 2 5 KiD6--EI/�EGt/� `t
ARCEL NUMBER: (`c 3 2 (// Oy• 0 a
CITY: STATE:
OWNER NAME: fZ l -7 -1 SIAID
CITY:
PHONE NUMBER:
ZIP CODE:
ADDRESS:
STATE: ZIP CODE:
?ZZ -O2Z/
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
-Q t3 /37
CONTRACTOR: ei(/1 ' 4-1,ki , 4-(//¢ %�Der' ADDRESS:
CITY: ( ,44� Gt//L1/71 STATE: (/v/9 Z I P CODE: 7%�2ED5
PHONE NUMBER: (.s!%% 93s -
STATE CONTRACTORS LICENSE NUMBER: Oke/P",4,--.0-7y2;
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? Y S
INTERIOR ALTERATION BY: JI
I
ADDRESS:
CITY:
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 $ S�
APPLICANT
SIGNATURE:
DATE:
9/4'
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675