1994, 03-25 Permit App: 94002447 Sewer 45374 . i315 " . CI4 . Z /41
Lr0 etaM'0 of SEWER CONNECTION PERMIT APPLICATION FORM G] j,
L-1 8 Z I , ( .io3w 14,5 --31 .
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED
(IF KNOWN)
JOB ADDRESS : _� 3 e9 ..,. 4- t 7L-- PARCEL NUMBER:
CITY: �1---- STATE: 9Z%' .. ZIP CODE: 99 0s"
OWNER NAME: ;,
ADDRESS: --z c-- ---P
CITY: �7 STATE: ZIP CODE:
PHONE NUMBER: f 2 2C 1
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: M5 pr'1n CDCCf-(v, V,-hon ADDRESS : 4) 1D. PX7X_ IL-1-2,F32..
CITY: ,5c�, ,ev), STATE: v./Ar ZIP CODE: g q 2 4.
PHONE NUMBER: 9 c • O 55 cr
STATE CONTRACTORS LICENSE NUMBER: A A M "(G-Ye 11 2-4 3-
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES (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. �J
SEWER CONNECTION • # OF BUILDINGS X 50. 00 = ,..!; e .
INTERIOR PLUMBING ALTERATIONS : # OF BUILDINGS X 35. 00 =
TOTAL PERMIT FEE DUE $
APPLICANT / 1ST"_
SIGNATURE:: DATE: .6 S /�,
/� _--.`//���
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675