1994, 03-03 Permit App: 94001668 Sewer - , CI it '- ile'L'g
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED .
( IF KNOWN )
JOB ADDRESS: 6,, .33-73- 47 G.p4wle]-- PARCEL NUMBER: ..
CITY . STATE: / II
ZIP CODE: gg�26
OWNER NAME: k&4 , ADDRESS:
CITY: STATE: PHONE: 9�(?--/S?
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES 0
( CIRCLE 0
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE .UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR:_a_51_,5___ CO f1.5�"(• A.c±jan ADDRESS: I8 )1 e. Vai lel vsrrAy
CITY: -6poie.a11Q. STATE: WA PHONE: SOq - q2.6 • $Q ,1-1-
ag20 40
STATE CONTRACTORS LICENSE NUMBER . . : 45 CON )4.* 123 Kc
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES ' ( CIRCLE ONE)
INTERIOR ALTERATION WORK BY . . : •
ADDRESS: PHONE:
CITY: STATE: ZIP CODE:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING , SHOP , GARAGE , ETC
THAT WILL BE CONNECTED TO THE SEWER.
I.
SEWER CONNECTION : 0 OF BUILDINGS / X 50 .00 = 5-2-0'
INTERIOR
INTERIOR PLUMBING ALTERATIONS: It OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $ ."
APPLICANT
SIGNATURE 472,1a/ A1.4-5
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675