1994, 02-22 Permit App: 94001365 Sewer CI-LP/36
1Lt5 .113
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SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED .
( IF KNOWN )
JOB ADDRESS: 31- C S ILc
SS Lo ij S)f , PARCEL NUMBER:
CITYP(1k<PktO �( STATE: I N - ZIP CODE:
�P ADDRESS: 34 k -1 S - SUct� OuoN 'OR
OWNER NAME: � ��R� 1 S
CITY:S�b���� t
STATE: W N , PHONE: q 2 .
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES(YISCLE 0 "NO
*IF PROPERTY OWNER INSTALLNGSEWER, THEY MUST REQUIREMENTS BEFOREIRST PERMITNISCISSUEDUTILITIES
DEPARTMENT FOR CONSTRUCTION
TLC- CNSTeUC.,T(ON ADDRESS: E. t3Uo Z1-" AVE
CONTRACTOR: Zl?
CITY: SPc:ASANJ . S AfiE' ggak(0 PHONE: Gad
STATE CONTRACTORS LICENSE NUMBER . . : CCO i0 7M L
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY . . :
ADDRESS: PHONE:
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 l X 50 .00 = 50 , 0r,
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 = � Orl
TOTAL PERMIT FEE DUE s � V
APPLICANT t
SIGNATURE_ • C6>4"1"46kAtsZ}
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WFST 1026 BROADWAY AVENUE SPOKANE,WA 99260 ( 509 )456-3675