1994, 02-28 Permit App: 94001592 Sewer 93 . o c11-1-- 15--q-
6.413
11-1-- C �l
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SEWER CONNECTION PERMIT APPLICATION FORM q
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED . n
�} ( IF KNOWN)
JOB ADDRESS: 3 , % C1 h' U-ev'Si T-� PARCEL NUMBER:
CITY: 'c'i<ct "`-` STATE: LO ZIP CODE:
OWNER NAME: � i C.K Y IS LA- h ADDRESS: S> S 0 q l.',vi ✓ Y S i I-Y'
CITY: S e v v* STATE: U`-)A- PHONE:
PROPERTY OWNER PERFORMING SEWER CONNECTION _ INSTALLATION? YES NO
(CISCLE
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: 0)\-l tLkS kde- S�i'otcc, ADDRESS: q_ - 110 li D-3 C d°"` -� -
CITY: \.sZ,‘Cu-c\ulQ_ STATE: L� PHONE: Cts ;-5g11 S / ci'z� - E'S73
STATE CONTRACTORS LICENSE NUMBER. . : C-IAAA ck-- 5 S 0'71 P 4
UTILIT]ES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES (.19 (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 I X 50.00 = S0°0 0
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $
/
P _
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or-
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675