1994, 03-14 Permit App: 94001989 Sewer . 94- - iqg
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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 .
:31( 07 `� ( IF KNOWN )
JOB ADDRESS: 11�+ " StANA M O Aj PARCEL NUMBER:
CITY:5 O 416, STATE: /A)/q,, ZIP CODE:
OWNER NAME: 117?i0 COOPER ADDRESS: G
CITY: STATE: PHONE: /, ?- 7709
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? (CES NO
SCLE ONE
*IF PROPERTY OWNER INSTALLING
REQUIREMENTS BEFOREFIRST
PERMITCONTACT
UTILITIES
ISSUED
DEPARTMENT FOR C�ONSIRO�GI LJrjc ,
((�J,,
CONTRACTOR: -Ite6PS44ADDRESS: E. L3j0 i2 AVE
CITY: SiPOKAAE (,6A SKATE": qqa'(° PHONE: qa1
STATE CONTRACTORS LICENSE NUMBER . . : LCC O A'`O 7T1 CQ
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 / X 50 .00 .5D• OC7
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $527 ,00
APPLICANT //�
SIGNATURE . ••
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
1 n7A BROADWAY AVENUE SPOKANE,WA 99260 ( 509)456-3675