1994, 02-22 Permit App: 94001366 Sewer qL - 1310L,
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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 .
t ( ( IF KNOWN)
JOB ADDRESS:: 3 ` ` SI Sc�►��o� �� . PARCEL NUMBER:
CITY: O RN F=- ( STATE: U f _ ZIP CODE:
OWNER NAME: 1"�
S
*� k _ �WA)0t ADDRESS: 3�l k Si S u,1ADU3 -
�
CITY: ��
� V STATE: ()0Q4 - PHONE: CMG - N 73
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? (CES 0
ISCLE ONE)
*IF PROPERTY OWNER INSTAGSEWER , THEY MUST REQUIREMENTS BEFOREIRST PERMIOTNISCT THE ISSUEDUTILITIES
DEPARTMENT FOR CONSTRUCTION
CONTRACTOR:
TLS- CoNSTeuC-T(ON ADDRESS: E, 13816 i2141 AVE
CITY: SPc)KAAE. 43A S-T-AfiE= qq -' ° PHONE: qa`1 -(01br
STATE CONTRACTORS LICENSE NUMBER. . : LCCO't*'-0 7M LQ
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 1 X 50 .00 = 50 ,00
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $ 5-010
APPLICANT " CE)AAA4A:��
SIGNATURE /�
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
L1FST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509 )456-3675