1994, 09-29 Permit App: 94009777 Sewer 05/16/1993 22:13 509-9284306 RON SLOAN PAGE 01
I
SEWER CONNECTION PERMIT APPLICATION FORM :ILLS
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AN?)
SIGNED OR PERMIT WILL NOT BE ISSUED.
/ .7/ 9 �' (IF KNOWN)
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JOADDRESS: 7 -d , .. £ PARCEL NUMBER:
CITY: STATE: )GJ ZIP CODE:, c/9 ? /
OWNER NAME: ..GSC ADDRESS:
CITY: STATE: ZIP CODE: �'-
PHONE NUMBER: L y'3S o 0
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: A l u1a‘f, ADDRESS: An_ jun 141.5G,2_ ,..,_ __,
CITY: , r e. STATE: WA ZIP CODE: g42.l►-1
PHONE _ 1
NUMBER: q2-1- g c n t?
STATE CONTRACTORS LICENSE NUMBER: A L v J/k1/A 106, f 5
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATION ; YES NO (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS : PHONE NUMBER:
CITY: STATE: IP CODE:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT W"LI:
BE CONNECTED TO THE SEWER.
SEWER CONNECTION OF BUILDINGS X 50.00 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35. 00 -
TOTAL PERMIT FEE DUE $ C-0
APPLICANT 7/? /
SIGNATURE: �-:: � DATE:
2 i'_..•. ..._
SPOKANE COUNTY DEPT.. OF BUILDINGS
WEST 1026 BROADWAY AVENUE.
SPOKANE, OSA 99260
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