1994, 04-15 Permit App: 94003203 Sewer`q45— /o?
ppn,14rda
SEWER CONNECTION PERMIT APPLICATION FORM L 2 -5
r3 �
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
(IF WN)
JOB ADDRESS: 3 (nO q �. �� \ La.) '\ PARCELONUMBER: g5 --.3z1„ „ r0/Ce
CITY :60r) 0. tn Q STATE: L.) A ZIP CODE: 461 -an (P
OWNER NAME: R 10 Sc k (` (+? ADDRESS : to f1 Cl a . Si 1 v► anr,1
CITY: S po Ka V\-(3' STATE: LJ <Pc ZIP CODE: -lc{ a 0 Co
PHONE NUMBER: 4 -._-a,- CSS 1 '1
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE 0
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: (" o (),S { 12 O -- o n ADDRESS: '16 I L , 8rr o vJGL,/
CITY: '>,()n,V.ruf c STATE: 116t ZIP CODE: qQ II 2,
PHONE NUMBER: R c{ f - q,a tact n
STATE CONTRACTORS LICENSE NUMBER: Z e r -S r C. - q 71
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES
INTERIOR ALTERATION BY:
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 = (D -CSO
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $ (D (ID
APPLICANT
SIGNATURE:
DATE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675