1994, 03-03 Permit App: 94001675 SewerH53 M_ i pzz,
L Lg SEWER�� CONNECTION PE IT APPLI T N FORM
Ul
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS : a -2Q y (,( U1 CJ co
CITY :'f7) Roc ►1 -2 STATE: ())
OWNER NAME : C H 1(\
CITY:���
- 7s
qqL5 - 2_24
IN ITS ENTIRETY AND
(IF KNOWN)
PARCEL NUMBER:
ZIP CODE: R
ADDRESS: 3 ] D `7 6ctaciato
STATE: W f\ ZIP CODE: C g C) t
PHONE NUMBER:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE ON
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: PoI'\Siru-t-Lon ADDRESS: / CP E , t Od-clW��
CITY: pn �'cC►,-��"
PHONE NUMBER: Z5 l ( `
STATE CONTRACTORS LICENSE NUMBER: -7__Rces -"'CD_* O 1-1
STATE: LJJ ZIP CODE: 99' 1
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS:
CITY:
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 I X 50.00 = 5-1 "VC?
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $ .5Th QiO
APPLICANT
SIGNATURE:
DATE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675