1994, 03-02 Permit App: 94001628 Sewer q -i3 . a4)LL-1- 9L - V
SEWER CONNECTION PERMIT APPLICATION FORM '1(4(5
2-13
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS : / 03,1 PARCEL NUt �����e.� .\/ (I F LON )
MBER:
PICITY: �/L� STATE: ZIP CODE: ic�)C ,
OWNER NAME: 60w r 1 S ADDRESS : /0d-1, (4.) ,rS
CITY: �jOv/iC (-- STATE: L-Ifil5 ZIP CODE: (/- )
PHONE NUMBER: 6V— 7/6
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE 0
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: / n z ��
//(;)4YADDRESS : /PO � �� ✓�
CITY: � /cC STATE: (-a ZIP CODE: 9%� 0
PHONE NUMBER: f4 73 41 c
STATE CONTRACTORS LICENSE NUMBER: b00/k-149(/. 5.6
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (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 = S d
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35. 00 =
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE: . 11rp
DATE: W5//
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675