1994, 03-11 Permit App: 94001945 SewerSEWER CONNECTION PERMIT APPLICATION FORM
ick4s
ads zL3
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
(IF KNOWN)
JOB ADDRESS : 2- /O 5;- man d02.A PARCEL NUMBER: p,
CITY: L ff O42 I t- STATE: illi 1f ZIP CODE: % 90 &-/
OWNER NAME :110K.L C _: ''9 !4 S 1 . Cr ADDRESS : O ( S E 2 o s wAv 1)( 0
CITY: S/001..A100 -�► E STATE: CVA ZIP CODE: 792-0S
PHONE NUMBER: 'Z i3 ' --40"--
PROPERTY
-40 Q ).
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
EIRCLE ON
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR:t_. ��'''�dLL'' O�-C-lot'+ * - y ADDRESS: X) . /Z /Z- O tl,�v» .O.4h
STATE:1./1/4 ZIP CODE: 9i'2_ 0
CITY: 5300 lv o C
PHONE NUMBER: 99(1-
/ g ° 1 3
STATE CONTRACTORS LICENSE NUMBER:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS: PHONE NUMBER:
CITY: 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: 3-i( -9
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675