1994, 06-03 Permit App: 94005022 Sewer01117/1993 19:30 509-9284306
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THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
SEWER CONNECTION PERMIT APPLICATION FORM
PAGE 01
OB ADDRESS:
(IF KNOWN) ' tcc r
PARCEL NUMBER: ✓ 3�' "`"'�"7
ITY: 5_`P014A- JE STATE: WA ZIP CODE: gCIZ-CSc'
'iNER NAME: - 7Rb\:30C ADDRESS:
ITY: �� STATE: ZIP CODE:
_ B-3.
2OPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE ONE)
TONE NUMBER: 46(0
CF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
)EPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT I8 ISSUED.
)NTRACTOR:
ADDRESS: .P_(�.Z-
:TY: „51)00.1)z STATE:_ W4 ZIP CODE: gA204.
IONE NUMBER : -
`ATE CONTRACTORS LI CENSE NUMBER : A W A 1/ A *E- L p
'ILITIES INSTALLERS PERMIT NUMBER:
ITERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
FTERIOR ALTERATION 8Y:
►DRESS:
STATE:
PHONE NUMBE
P CODE:
=====mammi======t1==============================m======MMWMmummomm========
WE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL
1E CONNECTED TO THE SEWER.
;EWER CONNECTION .if OF BUILDINGS X 50.00
CNTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS. X 35.00 =
TOTAL PERMIT FEE DUE $
'PLICANT
GNATURE:
DATE: Le-- \ —C1 1
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675
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