1994, 09-25 Permit App: 94009417 Sewer SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR O PERMIT WILTF L NOT BE ISSUED.
JOB ADDRESS: 3 '121 QX tI (IF PARCELLONN)
ENUMBER: (4 S Z) Z . ( 2-D LI
CITY : j 0vCa ti SE: W C'
� 'LP ZIP CODE: IC(2-0
OWNER NAME: 5A- Lcvv�oZ ADDRESS: IU IZ1; 6 'CI 1 Yui(
CITY: 01K- - STATE: LCA ZIP CODE: Ci4 ZI Zs
PHONE NUMBER: 1"- 4-1 - S2C10
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YESQ.
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQ( 7. )
IREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: A v A G0�'L �Y�-�C 1 L��� (1 > ADDRESS: EZOL 12t AJT-
CITY: SI'DICA A STATE: 1-k-j ZIP CODE: (“-i z �
PHONE NUMBER: L2,11 - 11Th
STATE CONTRACTORS LICENSE NUMBER:
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.
SEWER CONNECTION ' # OF BUILDINGS X 50. 00 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35. 00 =
TOTAL PERMIT FEE DUE $
APPLICANT 4.4 �}
SIGNATURE: � DATE: q/)SJW
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675